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Wilson-Barthes M, Steingrimsson J, Lee Y, Tran DN, Wachira J, Kafu C, Pastakia SD, Vedanthan R, Said JA, Genberg BL, Galárraga O. Economic outcomes among microfinance group members receiving community-based chronic disease care: Cluster randomized trial evidence from Kenya. Soc Sci Med 2024; 351:116993. [PMID: 38781744 PMCID: PMC11180555 DOI: 10.1016/j.socscimed.2024.116993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/15/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Poverty can be a robust barrier to HIV care engagement. We assessed the extent to which delivering care for HIV, diabetes and hypertension within community-based microfinance groups increased savings and reduced loan defaults among microfinance members living with HIV. METHODS We analyzed cluster randomized trial data ascertained during November 2020-May 2023 from 57 self-formed microfinance groups in western Kenya. Groups were randomized 1:1 to receive care for HIV and non-communicable diseases in the community during regular microfinance meetings (intervention) or at a health facility during routine appointments (standard care). Community and facility care provided clinical evaluations, medications, and point-of-care testing. The trial enrolled 900 microfinance members, with data collected quarterly for 18-months. We used a two-part model to estimate intervention effects on microfinance shares purchased, and a negative binomial regression model to estimate differences in loan default rates between trial arms. We estimated effects overall and by participant characteristics. RESULTS Participants' median age and distance from a health facility was 52 years and 5.6 km, respectively, and 50% reported earning less than $50 per month. The probability of saving any amount (>$0) through purchasing microfinance shares was 2.7 percentage points higher among microfinance group members receiving community vs. facility care. Community care recipients and facility care patients saved $44.90 and $25.24 over 18-months, respectively, and the additional amount saved by community care recipients was statistically significant (p = 0.036). Overall and in stratified analyses, loan defaults rates were not statistically significantly different between community and facility care patients. CONCLUSIONS Receiving integrated care in the community was significantly associated with modest increases in savings. We did not find any significant association between community-delivered care and reductions in loan defaults among HIV-positive microfinance group members. Longer follow up examination and formal mediation analyses are warranted.
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Affiliation(s)
- M Wilson-Barthes
- Brown University School of Public Health, International Health Institute, Providence, RI, USA.
| | - J Steingrimsson
- Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA
| | - Y Lee
- Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA
| | - D N Tran
- Temple University, School of Pharmacy, Philadelphia, PA, USA
| | - J Wachira
- Moi University College of Health Sciences, School of Medicine, Department of Behavioral Science, Eldoret, Kenya
| | - C Kafu
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - S D Pastakia
- Purdue University College of Pharmacy, Center for Health Equity and Innovation, Indianapolis, IN, USA
| | - R Vedanthan
- New York University Grossman School of Medicine, Department of Population Health, New York, NY, USA
| | - J A Said
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - B L Genberg
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - O Galárraga
- Brown University School of Public Health, Department of Health Services, Policy and Practice; and International Institute, Providence, RI, USA
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Verjans A, Hooley B, Tani K, Mhalu G, Tediosi F. Cross-sectional study of the burden and determinants of non-medical and opportunity costs of accessing chronic disease care in rural Tanzania. BMJ Open 2024; 14:e080466. [PMID: 38553069 PMCID: PMC10982752 DOI: 10.1136/bmjopen-2023-080466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 03/06/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVES Countries in sub-Saharan Africa are seeking to improve access to healthcare through health insurance. However, patients still bear non-medical costs and opportunity costs in terms of lost work days. The burden of these costs is particularly high for people with chronic diseases (CDs) who require regular healthcare. This study quantified the non-medical and opportunity costs faced by patients with CD in Tanzania and identified factors that drive these costs. METHODS From November 2020 to January 2021, we conducted a cross-sectional patient survey at 35 healthcare facilities in rural Tanzania. Using the human capital approach to value the non-medical cost of seeking healthcare, we employed multilevel linear regression to analyse the impact of CDs and health insurance on non-medical costs and negative binomial regression to investigate the factors associated with opportunity costs of illness among patients with CDs. RESULTS Among 1748 patients surveyed, 534 had at least one CD, 20% of which had comorbidities. Patients with CDs incurred significantly higher non-medical costs than other patients, with an average of US$2.79 (SD: 3.36) compared with US$2.03 (SD: 2.82). In addition, they incur a monthly illness-related opportunity cost of US$10.19 (US$0-59.34). Factors associated with higher non-medical costs included multimorbidities, hypertension, health insurance and seeking care at hospitals rather than other facilities. Patients seeking hypertension care at hospitals experienced 35% higher costs compared with those visiting other facilities. Additionally, patients with comorbidities, older age, less education and those requiring medication more frequently lost workdays. CONCLUSION Outpatient care in Tanzania imposes considerable non-medical costs, particularly for people with CDs, besides illness-related opportunity costs. Despite having health insurance, patients with CDs who seek outpatient care in hospitals face higher financial burdens than other patients. Policies to improve the availability and quality of CD care in dispensaries and health centres could reduce these costs.
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Affiliation(s)
- Anna Verjans
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Brady Hooley
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Kassimu Tani
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Grace Mhalu
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
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Meghji J, Gunsaru V, Chinoko B, Joekes E, Banda NPK, Marozva N, Rylance J, Squire SB, Mortimer K, Lesosky M. Screening for post-TB lung disease at TB treatment completion: Are symptoms sufficient? PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002659. [PMID: 38285713 PMCID: PMC10824425 DOI: 10.1371/journal.pgph.0002659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/12/2023] [Indexed: 01/31/2024]
Abstract
Pulmonary TB survivors face a high burden of post-TB lung disease (PTLD) after TB treatment completion. In this secondary data analysis we investigate the performance of parameters measured at TB treatment completion in predicting morbidity over the subsequent year, to inform programmatic approaches to PTLD screening in low-resource settings. Cohort data from urban Blantyre, Malawi were used to construct regression models for five morbidity outcomes (chronic respiratory symptoms or functional limitation, ongoing health seeking, spirometry decline, self-reported financial impact of TB disease, and death) in the year after PTB treatment, using three modelling approaches: logistic regression; penalised regression with pre-selected predictors; elastic net penalised regression using the full parent dataset. Predictors included demographic, clinical, symptom, spirometry and chest x-ray variables. The predictive performance of models were examined using the area under the receiver-operator curve (ROC AUC) values. Key predictors were identified, and their positive and negative predictive values (NPV) determined. The presence of respiratory symptoms at TB treatment completion was the strongest predictor of morbidity outcomes. TB survivors reporting breathlessness had higher odds of spirometry decline (aOR 20.5, 95%CI:3-199.1), health seeking (aOR 10.2, 2.4-50), and symptoms or functional limitation at 1-year (aOR 16.7, 3.3-133.4). Those reporting activity limitation were more likely to report symptoms or functional limitation at 1-year (aOR 4.2, 1.8-10.3), or severe financial impact of TB disease (aOR2.3, 1.0-5.0). Models were not significantly improved by including spirometry or imaging parameters. ROC AUCs were between 0.65-0.77 for the morbidity outcomes. Activity limitation at treatment completion had a NPV value of 78-98% for adverse outcomes. Our data suggest that whilst challenging to predict the development of post-TB morbidity, the use of symptom screening tools at TB treatment completion to prioritise post-TB care should be explored. We identified little benefit from the additional use of spirometry or CXR imaging.
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Affiliation(s)
- Jamilah Meghji
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Vester Gunsaru
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Beatrice Chinoko
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Ndaziona P. K. Banda
- Department of Medicine, Kamuzu University of Health Sciences and Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Nicola Marozva
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
| | - Jamie Rylance
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Stephen B. Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Kevin Mortimer
- Department of Respiratory Medicine, Liverpool University Hospitals National Health Service Foundation Trust, Liverpool, United Kingdom
| | - Maia Lesosky
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
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Idrus LR, Fitria N, Purba FD, Alffenaar JWC, Postma MJ. Analysis of Health-Related Quality of Life and Incurred Costs Among Human Immunodeficiency Virus, Tuberculosis, and Tuberculosis/HIV Coinfected Outpatients in Indonesia. Value Health Reg Issues 2024; 41:32-40. [PMID: 38194897 DOI: 10.1016/j.vhri.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/30/2023] [Accepted: 10/25/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVES A growing interest in healthcare costs and patients' health-related quality of life (HRQoL) exists in the context of the increasing importance of health technology assessment in countries with high numbers of the HIV and tuberculosis (TB) patient populations, such as Indonesia. This study aimed to analyze the HRQoL and out-of-pocket (OOP) costs of HIV, TB, and TB/HIV coinfected participants in a city in Indonesia with a high prevalence of HIV and TB. METHODS A cross-sectional survey was conducted in the voluntary counseling and testing and lung clinics of Bekasi City Public Hospital (Indonesia) from January to March 2018. Patients' HRQoL was measured using the EQ-5D-5L questionnaire, whereas OOP costs were extracted from a semistructured questionnaire. RESULTS Of the 460 eligible participants, 82% resided in the city, 48% of them were married, and their median age was 34 years. Less than half were insured, and more than half had no source of income. The median values of health utilities for participants with HIV, TB, and TB/HIV were perceived as potentially high (1.0, 0.9, and 0.8, respectively). The TB/HIV coinfected outpatients had the highest OOP costs (US$94.5), with the largest contribution coming from direct medical OOP expenditures. Taking loans from family members was adopted as a financial strategy to overcome inadequate household incomes and high treatment costs. CONCLUSION This study suggests that TB/HIV coinfection potentially lowers HRQoL and increases healthcare costs and the need for economic analysis to underpin cost-effective treatment in such patients.
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Affiliation(s)
- Lusiana R Idrus
- Unit of PharmacoTherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands; Department of Pharmacy, Bekasi City Public Hospital, Bekasi City, West Java, Indonesia.
| | - Najmiatul Fitria
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Andalas, Padang, West Sumatra, Indonesia
| | - Fredrick D Purba
- Department of Psychology, Faculty of Psychology, Universitas Padjadjaran, Bandung, Indonesia
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Westmead Hospital, Sydney, Australia; Sydney Infectious Diseases Institute, University of Sydney, Sydney, Australia
| | - Maarten J Postma
- Unit of PharmacoTherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands; Unit of Global Health, Department of Health Sciences University Medical Centre Groningen (UMCG), University of Groningen, Groningen, The Netherlands; Institute of Science in Healthy Ageing and HealthcaRE (SHARE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Department of Economics, Econometrics and Finance, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
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Beidelman ET, Bärnighausen T, Wing C, Tollman S, Phillips ML, Rosenberg M. Disease awareness and healthcare utilization in rural South Africa: a comparative analysis of HIV and diabetes in the HAALSI cohort. BMC Public Health 2023; 23:2202. [PMID: 37940928 PMCID: PMC10634006 DOI: 10.1186/s12889-023-17043-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 10/21/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Studies from rural South Africa indicate that people living with HIV (PLHIV) may have better health outcomes than those without, potentially due to the frequent healthcare visits necessitated by infection. Here, we examined the association between HIV status and healthcare utilization, using diabetes as an illustrative comparator of another high-burden, healthcare-intensive disease. METHODS Our exposure of interest was awareness of positive disease status for both HIV and diabetes. We identified 742 individuals who were HIV-positive and aware of their status and 305 who had diabetes and were aware of their status. HIV-positive status was further grouped by viral suppression. For each disease, we estimated the association with (1) other comorbid, chronic conditions, (2) health facility visits, (3) household-level healthcare expenditure, and (4) per-visit healthcare expenditure. We used log-binomial regression models to estimate prevalence ratios for co-morbid chronic conditions. Linear regression models were used for all other outcomes. RESULTS Virally suppressed PLHIV had decreased prevalence of chronic conditions, increased public clinic visits [β = 0.59, 95% CI: 0.5, 0.7], and reduced per-visit private clinic spending [β = -60, 95% CI: -83, -6] compared to those without HIV. No differences were observed in hospitalizations and per-visit spending at hospitals and public clinics between virally suppressed PLHIV and non-PLHIV. Conversely, diabetic individuals had increased prevalence of chronic conditions, increased visits across facility types, increased household-level expenditures (β = 88 R, 95% CI: 29, 154), per-visit hospital spending (β = 54 R, 95% CI: 7, 155), and per-visit public clinic spending (β = 31 R, 95% CI: 2, 74) compared to those without diabetes. CONCLUSIONS Our results suggest that older adult PLHIV may visit public clinics more often than their HIV-negative counterparts but spend similarly on a per-visit basis. This provides preliminary evidence that the positive health outcomes observed among PLHIV in rural South Africa may be explained by different healthcare engagement patterns. Through our illustrative comparison between PLHIV and diabetics, we show that shifting disease burdens towards chronic and historically underfunded diseases, like diabetes, may be changing the landscape of health expenditure inequities.
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Affiliation(s)
- Erika T Beidelman
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, 1025 E. 7th St, Bloomington, IN, 47405, USA.
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Heidelberg, Germany
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt School of Public Health), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Coady Wing
- O'Neill School of Public and Environmental Affairs, Indiana University-Bloomington, Bloomington, USA
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt School of Public Health), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Meredith L Phillips
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, 1025 E. 7th St, Bloomington, IN, 47405, USA
| | - Molly Rosenberg
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, 1025 E. 7th St, Bloomington, IN, 47405, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt School of Public Health), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Lamloum D, Fassio F, Osetinsky B, Tediosi F. Care Cascades for Hypertension in Low-Income Settings: A Systematic Review and Meta-Analysis. Int J Public Health 2023; 68:1606428. [PMID: 37901590 PMCID: PMC10600349 DOI: 10.3389/ijph.2023.1606428] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/28/2023] [Indexed: 10/31/2023] Open
Abstract
Objective: High blood pressure is the leading risk factor for cardiovascular disease. The hypertension care cascade (HCC) is increasingly being used to evaluate the effectiveness of interventions. This systematic review aims to examine HCC in low-income settings. Methods: The search strategy included articles published between January 2010 and April 2023. We excluded studies with incomplete HCC, on fragile patients or aged <18 years, reviews. We used the MOOSE guideline. Five researchers retrieved data on the survey year, country, population, HCC and diagnostic methods for hypertension. We used JBI Critical Appraisal Tools for quality assessment. Results: Ninety-five articles were analyzed. Average hypertension prevalence was 33% (95% CI: 31%-34%), lower in LICs than in LMICs (25% vs. 34%). The overall mean awareness of hypertension was 48% (95% CI: 45%-51%), its treatment was 35% (95% IC: 32%-38%) and its control 16% (95% CI: 14%-18%). In almost all steps, percentages were lower in LICs and in Sub-Saharan Africa. Conclusion: Trends in HCC vary between countries, with poorer performance in LICs. This review highlights the need for interventions tailored to low-income settings in order to improve hypertension care.
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Affiliation(s)
- Demetrio Lamloum
- Department of Preventive, Restorative and Pediatric Dentistry, University of Bern, Bern, Switzerland
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Federico Fassio
- Department of Public Health, Experimental and Forensic Medicine, Section of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
| | - Brianna Osetinsky
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabrizio Tediosi
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Kagura J, Khamisa N, Matsena Zingoni Z, Dulaze N, Awuku-Larbi Y, Tshuma N. Patient satisfaction with chronic disease care and its associated factors in primary health care facilities in Johannesburg, South Africa. FRONTIERS IN HEALTH SERVICES 2023; 3:967199. [PMID: 37304754 PMCID: PMC10254081 DOI: 10.3389/frhs.2023.967199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 04/04/2023] [Indexed: 06/13/2023]
Abstract
Background Patient satisfaction is a widely used indicator of assessing health care quality and has been used by policymakers to consider the needs of patients when developing suitable strategies for safe and high-quality care. However, in South Africa, the dual burden of HIV and NCDs has implications for the health system, whereby the factors influencing the quality of care and patient satisfaction may be unique to this context. Thus, this study examined the predictors affecting chronic disease patients' levels of satisfaction with care in Johannesburg, South Africa. Methods A cross-sectional study was conducted among 2,429 chronic disease patients at 80 primary healthcare facilities in Johannesburg, South Africa. A questionnaire derived from existing literature and patient satisfaction frameworks was used to measure the level of satisfaction of patients when receiving care. Patients' overall satisfaction was categorized into not satisfied and satisfied. Cronbach's alpha was used to assess scale reliability. Factor analysis was used as a data dimension reduction approach and the Kaiser-Meyer-Olkin and the Bartlett test of sphericity were used to test the sampling adequacy and to examine the inter-independence of the items. Logistic regression was used to determine factors associated with being satisfied. Significance was set at 5%. Results The majority of chronic disease patients 65.5% (n = 1,592) were aged 18-30 years; 63.8% (n = 1,549) were females, 55.1% (n = 1,339) were married and 2,032 (83.7%) were satisfied with care. The factor analysis results were in five sub-scales namely improving values and attitudes, cleanliness of the clinic, safe and effective care, infection control, and on the availability of medicines. In adjusted models, patients aged >51years had an increased odds of 3.18 (95% CI:1.31-7.75) of being satisfied compared to those aged 18-30 years and patients who had visited the clinic at least 6 times had 51% increased odds of being satisfied (AOR = 1.51,95% CI:1.13-2.03). The odds of being satisfied increased by 28% (AOR = 1.28,95% CI:1.07-1.53), 45% (AOR = 1.45,95% CI:1.2-1.75), 34% (AOR = 1.34,95% CI:1.13-1.59) and 4.31 (95% CI:3.55-5.23) for every score increase in the factors like improving values and attitudes, cleanliness of clinic safe and effective care and availability of medicine, respectively. Conclusions Key predictors of patient satisfaction were found to be sociodemographic factors including age, distance to the clinic, number of visits and waiting times as well as factors such as improving values and attitudes, cleanliness of the clinic, waiting time, safety and effective care and availability of medicines. Adjustment of existing frameworks for addressing context-specific improvement of patient experiences such as security and safety is recommended to ensure healthcare quality and service utilization for better chronic disease outcomes in South Africa.
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Affiliation(s)
- Juliana Kagura
- Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Natasha Khamisa
- Division of Health and Society, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Zvifadzo Matsena Zingoni
- Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Neo Dulaze
- Division of Bioethics and Health Law, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Yaw Awuku-Larbi
- Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Schröder H, Yapa HM, Gómez-Olivé FX, Thirumurthy H, Seeley J, Bärnighausen T, De Neve JW. Intergenerational spillover effects of antiretroviral therapy in sub-Saharan Africa: a scoping review and future directions for research. BMJ Glob Health 2023; 8:bmjgh-2022-011079. [PMID: 37068847 PMCID: PMC10111905 DOI: 10.1136/bmjgh-2022-011079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/24/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) may influence individuals who do not receive the intervention but who are connected in some way to the person who does. Relatively little is known, however, about the size and scope of, what we term, spillover effects of ART. We explored intergenerational spillover effects of ART in sub-Saharan Africa (SSA) and identified several directions for future research. METHODS We conducted a scoping review between March and April 2022. We systematically searched PubMed, PsycINFO, EconLit, OTseeker, AIDSInfo, Web of Science, CINHAL, Google Scholar and African Index Medicus. We analysed the distribution of included studies over time and summarised their findings. We examined the intergenerational impact of ART provision to working-age adults living with HIV on children ('downward' spillover effects) and older adults ('upward' spillover effects). We categorised types of intergenerational spillover effects according to broad themes which emerged from our analysis of included studies. FINDINGS We identified 26 studies published between 2005 and 2022 with 16 studies assessing spillover effects from adults to children (downward), and 1 study explicitly assessing spillover effects from working-age adults to older adults (upward). The remaining studies did not fully specify the direction of spillover effects. Most spillover effects of ART to household and family members were beneficial and included improvements in wealth, labour market outcomes, health outcomes and health services utilisation, schooling, and household composition. Both children and older adults benefited from ART availability among adults. Detrimental spillover effects were only reported in three studies and included financial and opportunity costs associated with health services utilisation and food insecurity in the first year after ART. CONCLUSIONS ART may lead to substantial spillover effects across generations and sectors in SSA. Further research is needed to capitalise on positive spillover effects while mitigating potential negative spillover effects. The returns to investments in large-scale health interventions such as ART may be underestimated without considering these societal benefits.
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Affiliation(s)
- Henning Schröder
- Heidelberg Institute of Global Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - H Manisha Yapa
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- The Kirby Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Francesc Xavier Gómez-Olivé
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Janet Seeley
- Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
- Africa Health Research Institute, Durban, South Africa
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
- Africa Health Research Institute, Durban, South Africa
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, USA
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
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Steinert JI, Shenderovich Y, Smith M, Zhou S, Toska E, Cluver L. Economic Well-being and Associated Mediating Pathways to Improved Antiretroviral Therapy Adherence Among Adolescents Living With HIV: A Prospective Cohort Study in South Africa. J Acquir Immune Defic Syndr 2022; 91:343-352. [PMID: 35969470 PMCID: PMC9592174 DOI: 10.1097/qai.0000000000003071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 07/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adolescents living with HIV exhibit lower levels of adherence to antiretroviral therapy (ART) than other age groups. Poverty is a key barrier to ART adherence. This study aims at understanding how alleviating poverty through structural and internal pathways can help increase ART adherence among adolescents. SETTING Eastern Cape province, South Africa. METHODS One thousand forty-six adolescents living with HIV were recruited from 53 public health care facilities and interviewed at 3 data collection waves with a retention rate of 89% and a mortality rate of 3%. Data were collected by face-to-face, device-assisted interviews. Hybrid probit regressions and a structural equation path analysis were used to estimate the association between poverty reduction (increased access to basic necessities) and the pathways by which it could improve ART adherence. RESULTS Self-reported ART adherence ranged from an average of 66% (n = 615) at baseline to 75% (n = 700) in the last wave. Within-person and between-person improvements in economic well-being were associated with significant increases in adolescent ART adherence. On average, adolescents with access to 3 additional basic needs experienced a 4 percentage-point increase in the probability of ART adherence. Structural pathways to improved ART adherence included participants having enough money to travel to the clinic and sufficient food to eat when taking medication. Internal pathways included improved psychological well-being and reduced internalized HIV stigma. CONCLUSION Poverty reduction programs such as HIV-sensitive social protection can address structural and psychological pathways to increase ART adherence among economically disadvantaged adolescents by incentivizing demand-side interventions and the provision of quality essential services.
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Affiliation(s)
- Janina Isabel Steinert
- TUM School of Social Sciences and Technology, Technical University of Munich, Munich, Germany
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, United Kingdom
| | - Yulia Shenderovich
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, United Kingdom
- Wolfson Centre for Young People's Mental Health, Cardiff University, Cardiff, United Kingdom
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, Cardiff, United Kingdom
| | - Michael Smith
- United Nations World Food Programme, Nutrition Division, Rome, Italy
| | - Siyanai Zhou
- Centre for Social Science Research
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine; and
| | - Elona Toska
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, United Kingdom
- Centre for Social Science Research
- Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Lucie Cluver
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, United Kingdom
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10
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Mutono N, Wright JA, Mutunga M, Mutembei H, Thumbi SM. Impact of traffic congestion on spatial access to healthcare services in Nairobi. FRONTIERS IN HEALTH SERVICES 2022; 2:788173. [PMID: 36925766 PMCID: PMC10012710 DOI: 10.3389/frhs.2022.788173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/25/2022] [Indexed: 11/17/2022]
Abstract
Background Geographic accessibility is an important determinant of healthcare utilization and is critical for achievement of universal health coverage. Despite the high disease burden and severe traffic congestion in many African cities, few studies have assessed how traffic congestion impacts geographical access to healthcare facilities and to health professionals in these settings. In this study, we assessed the impact of traffic congestion on access to healthcare facilities, and to the healthcare professionals across the healthcare facilities. Methods Using data on health facilities obtained from the Ministry of Health in Kenya, we mapped 944 primary, 94 secondary and four tertiary healthcare facilities in Nairobi County. We then used traffic probe data to identify areas within a 15-, 30- and 45-min drive from each health facility during peak and off-peak hours and calculated the proportion of the population with access to healthcare in the County. We employed a 2-step floating catchment area model to calculate the ratio of healthcare and healthcare professionals to population during these times. Results During peak hours, <70% of Nairobi's 4.1 million population was within a 30-min drive from a health facility. This increased to >75% during off-peak hours. In 45 min, the majority of the population had an accessibility index of one health facility accessible to more than 100 people (<0.01) for primary health care facilities, one to 10,000 people for secondary facilities, and two health facilities per 100,000 people for tertiary health facilities. Of people with access to health facilities, a sub-optimal ratio of <4.45 healthcare professionals per 1,000 people was observed in facilities offering primary and secondary healthcare during peak and off-peak hours. Conclusion Our study shows access to healthcare being negatively impacted by traffic congestion, highlighting the need for multisectoral collaborations between urban planners, health sector and policymakers to optimize health access for the city residents. Additionally, growing availability of traffic probe data in African cities should enable similar analysis and understanding of healthcare access for city residents in other countries on the continent.
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Affiliation(s)
- Nyamai Mutono
- Wangari Maathai Institute for Peace and Environmental Studies, University of Nairobi, Nairobi, Kenya
- Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
- Paul G. Allen School for Global Health, Washington State University, Pullman, WA, United States
| | - Jim A. Wright
- School of Geography and Environment Science, University of Southampton, Southampton, United Kingdom
| | - Mumbua Mutunga
- Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Henry Mutembei
- Wangari Maathai Institute for Peace and Environmental Studies, University of Nairobi, Nairobi, Kenya
- Department of Clinical Studies, University of Nairobi, Nairobi, Kenya
| | - S. M. Thumbi
- Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
- Paul G. Allen School for Global Health, Washington State University, Pullman, WA, United States
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
- Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, United Kingdom
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Costs incurred by patients with tuberculosis co-infected with human immunodeficiency virus in Bhavnagar, western India: a sequential explanatory mixed-methods research. BMC Health Serv Res 2022; 22:1268. [PMID: 36261837 PMCID: PMC9581761 DOI: 10.1186/s12913-022-08647-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND India reports the highest number of tuberculosis (TB) and second-highest number of the human immunodeficiency virus (HIV) globally. We hypothesize that HIV might increase the existing financial burden of care among patients with TB. We conducted this study to estimate the costs incurred by patients with TB co-infected with HIV and to explore the perspectives of patients as well as program functionaries for reducing the costs. METHODS We conducted a descriptive cross-sectional study among 234 co-infected TB-HIV patients notified in the Bhavnagar region of western India from 2017 to 2020 to estimate the costs incurred, followed by in-depth interviews among program functionaries and patients to explore the solutions for reducing the costs. Costs were estimated in Indian rupees (INR) and expressed as median (interquartile range IQR). The World Health Organization defines catastrophic costs as when the total costs incurred by patients exceed 20% of annual household income. The in-depth interviews were audio-recorded, transcribed, and analyzed as codes grouped into categories. RESULTS Among the 234 TB-HIV co-infected patients, 78% were male, 18% were sole earners in the family, and their median (IQR) monthly family income was INR 9000 (7500-11,000) [~US$ 132 (110-162)]. The total median (IQR) costs incurred for TB were INR 4613 (2541-7429) [~US$ 69 (37-109)], which increased to INR 7355 (4337-11,657) [~US$ 108 (64-171)] on adding the costs due to HIV. The catastrophic costs at a 20% cut-off of annual household income for TB were 4% (95% CI 2-8%), which increased to 12% (95% CI 8-16%) on adding the costs due to HIV. Strengthening health systems, cash benefits, reducing costs through timely referral, awareness generation, and improvements in caregiving were some of the solutions provided by program functionaries and the patients. CONCLUSION We conclude that catastrophic costs due to TB-HIV co-infection were higher than that due to TB alone in our study setting. Bringing care closer to the patients would reduce their costs. Strengthening town-level healthcare facilities for diagnostics as well as treatment might shift the healthcare-seeking of patients from the private sector towards the government and thereby reduce the costs incurred.
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12
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Mulqueeny DM, Taylor M. Patient-centred care: reality or rhetoric—patients’ experiences at ARV clinics located in public hospitals in KwaZulu-Natal, South Africa. AIDS Res Ther 2022; 19:41. [PMID: 36088340 PMCID: PMC9464375 DOI: 10.1186/s12981-022-00463-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 08/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background The South African public antiretroviral therapy (ART) programme is considered one of the largest and most successful ART programmes worldwide. Hence, a study exploring the patients’ experiences of the public antiretroviral therapy (ART) programme in the second decade of the programme is relevant as no study has been published on patients’ experiences at these sites. Objectives To explore patients’ experiences of care in the public ART programme at four ARV clinics within the eThekwini District, KwaZulu-Natal. Method A mixed-methods study design with 12 in-depth patient interviews, non-participatory observation, and a stratified random sample of 400 patients completed questionnaires. Qualitative data were thematically analysed. Quantitative data were analysed using a SPSS 24 package to determine frequencies and differences in patients’ responses (p < 0.05). The socio-ecological model framed the study. Results All 412 patients reported valuing the provision of free ARVs. Patients’ positive experiences included: routine blood results mostly being available, most staff greeted patients, there were sufficient nurses, patients were satisfied with the time that they spent with doctors, clean clinics, and private and safe counselling areas. The negative experiences included: poor relationships with nurses, negative staff attitudes, disrespectful staff, information was lacking, inadequate counselling at times, varying and inflexible appointments, challenges with data capture and registration systems; varying ARV collection frequencies, routine health tests and processes per site, and the absence of patient committees and representatives. Conclusion The results reflected positive and negative experiences which varied between the facilities, as processes and systems differed at each site. Innovative patient-centred processes and programmes could be implemented to ensure patients have mostly positive experiences. As part of continuous improvement, patients’ experiences should be regularly explored to ensure that the ART programme meets their needs and expectations.
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13
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Martin K, Wenlock R, Roper T, Butler C, Vera JH. Facilitators and barriers to point-of-care testing for sexually transmitted infections in low- and middle-income countries: a scoping review. BMC Infect Dis 2022; 22:561. [PMID: 35725437 PMCID: PMC9208134 DOI: 10.1186/s12879-022-07534-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Sexually transmitted infections (STIs) in low- and middle-income countries (LMICs) are predominantly managed by syndromic management. However, most STIs are asymptomatic. These untreated STIs cause individual morbidity, and lead to high STI prevalences. There is increasing interest in the use of point-of-care tests (POCTs) for STIs in LMICs, which could facilitate same day testing and treatment. To best utilise these tests, we must understand the facilitators and barriers to their implementation. The aim of this review is to explore how point-of-care testing for STIs has been implemented into healthcare systems in LMIC and the facilitators and barriers to doing so. Methods A scoping review was conducted by searching MEDLINE, Embase, Emcare, CINAHL, Scopus, LILACS, the Cochrane Library, and ProQuest Dissertations and Theses for studies published between 1st January 1998 and 5th June 2020. Abstracts and full articles were screened independently by two reviewers. Studies were considered for inclusion if they assessed the acceptability, feasibility, facilitators, or barriers to implementation of point-of-care testing for chlamydia, gonorrhoea, trichomoniasis or syphilis in LMICs. Thematic analysis was used to analyse and present the facilitators and barriers to point-of-care STI testing. Results The literature search revealed 82 articles suitable for inclusion; 44 (53.7%) from sub-Saharan Africa; 21 (25.6%) from Latin American and the Caribbean; 10 (12.2%) from East Asia and the Pacific; 6 (7.3%) from South Asia; and one (1.2%) multi-regional study. Thematic analysis revealed seven overarching themes related to the implementation of POCTs in LMICs, namely (i) Ideal test characteristics, (ii) Client factors, (iii) Healthcare provision factors, (iv) Policy, infrastructure and health system factors, (v) Training, audit, and feedback, (vi) Reaching new testing environments, and (vii) Dual testing. Conclusion Implementation of POCTs in LMICs is complex, with many of the barriers due to wider health system weakness. In addition to pressing for broader structural change to facilitate basic healthcare delivery, these themes may also be used as a basis on which to develop future interventions. The literature was heavily skewed towards syphilis testing, and so more research needs to be conducted assessing chlamydia, gonorrhoea, and trichomoniasis testing, as well as home or self-testing. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07534-9.
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Affiliation(s)
- Kevin Martin
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK. .,Biomedical Research and Training Institute, Harare, Zimbabwe. .,Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK.
| | - Rhys Wenlock
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Tom Roper
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Ceri Butler
- Department of Medical Education, Brighton and Sussex Medical School, Brighton, UK
| | - Jaime H Vera
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK.,University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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MORROW J, LAHER AE. Financial burden associated with attendance at a public hospital emergency department in Johannesburg. Afr J Emerg Med 2022; 12:102-105. [PMID: 35251920 PMCID: PMC8886001 DOI: 10.1016/j.afjem.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/01/2022] [Accepted: 02/08/2022] [Indexed: 11/19/2022] Open
Abstract
Poverty and inequality are two of the most significant issues affecting people living in Africa Catastrophic health care expenditure (CHCE), which is out-of-pocket expenditure on medical care that leads to a severe financial burden for the individual or household, affects 44 million individuals from 150 million households globally Various expenses including transport costs, general practitioner fees acquired prior to the EC visit, loans and loss of usual daily income contribute to the financial burden associated with a visit to the EC
Introduction: More than half of South Africans live below the poverty line. Indirect medical costs can contribute significantly to the financial burden of patients seeking medical care. The aim of this study was to determine the expenses incurred by patients and/or their escorts during a visit to the emergency centre (EC). Methods: Patients and/or their escorts presenting to an EC in Johannesburg were asked to complete the study questionnaire relating to expenses incurred during a visit to the EC. Results: Of the total 396 participants that completed the questionnaire, 108 (27.2%) did not have any source of income, 146 (36.9%) were the sole breadwinner in their household and 36 (9.1%) belonged to zero-income households. Among those earning ≤R2000 per month, the mean expenses relating to the EC visit was R240 (SD R372), equating to an average of 33.2% of mean monthly income. Transport costs were the most common expense (n=302, 76.3%), while general practitioner (GP) fees incurred prior to the EC visit accounted for the bulk of the expenses (median R450, IQR 350-820). Participants that earned >R2000 per month were significantly more likely to incur GP fees (p =0.012), while those earning ≤R2000 per month were significantly more likely to take a loan to cover EC related expenses (p =0.014). Conclusion: A visit to the EC can have a substantial financial impact on patients and their accompanying escorts in South Africa. Strategies should be aimed at identifying and assisting those that are in need of financial assistance to cover indirect healthcare costs.
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15
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Affiliation(s)
- Joseph Freer
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Vanessa Mudaly
- HIV/AIDS, Sexually Transmitted Infections, and Tuberculosis Directorate, Provincial Department of Health, Western Cape Government, Cape Town, South Africa
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Varshney K, Anaele B, Molaei M, Frasso R, Maio V. Risk Factors for Poor Outcomes Among Patients with Extensively Drug-Resistant Tuberculosis (XDR-TB): A Scoping Review. Infect Drug Resist 2021; 14:5429-5448. [PMID: 34938089 PMCID: PMC8687707 DOI: 10.2147/idr.s339972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
In recent years, there has been an upsurge in cases of drug-resistant TB, and strains of TB resistant to all forms of treatment have begun to emerge; the highest level of resistance is classified as extensively drug-resistant tuberculosis (XDR-TB). There is an urgent need to prevent poor outcomes (death/default/failed treatment) of XDR-TB, and knowing the risk factors can inform such efforts. The objective of this scoping review was to therefore identify risk factors for poor outcomes among XDR-TB patients. We searched three scientific databases, PubMed, Scopus, and ProQuest, and identified 25 articles that examined relevant risk factors. Across the included studies, the proportion of patients with poor outcomes ranged from 8.6 to 88.7%. We found that the most commonly reported risk factor for patients with XDR-TB developing poor outcomes was having a history of TB. Other risk factors were human immunodeficiency virus (HIV), a history of incarceration, low body mass, being a smoker, alcohol use, unemployment, being male, and being middle-aged. Knowledge and understanding of the risk factors associated with poor outcomes of XDR-TB can help policy makers and organizations in the process of designing and implementing effective programs.
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Affiliation(s)
- Karan Varshney
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Beverly Anaele
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew Molaei
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rosemary Frasso
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vittorio Maio
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
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17
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Chikafu H, Chimbari M. Hypertension care cascade in the Ingwavuma rural community, uMkhanyakude District, KwaZulu-Natal province of South Africa. PeerJ 2021; 9:e12372. [PMID: 34824908 PMCID: PMC8590801 DOI: 10.7717/peerj.12372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/01/2021] [Indexed: 12/02/2022] Open
Abstract
Background Treatment and control of hypertension are associated with a substantial reduction in adverse cardiovascular disease outcomes. Although South Africa aims to reduce the burden of cardiovascular diseases, there is limited evidence on the hypertension care cascade (HCC) performance in rural areas where stroke and hypertension are high. This study estimated HCC performance and identified predictors of hypertension screening among adults in the Ingwavuma community of KwaZulu-Natal, South Africa. Methods This was a cross-sectional study. Data were collected using the WHO STEPwise approach to surveillance (STEPS) questionnaire from 400 adult participants, excluding pregnant women and those with physical or cognitive impairments. Three hundred and ninety-three participants had complete data, and 131 had high blood pressure. We calculated progression rates for screening, diagnosis, treatment and control of hypertension from the sub-sample of participants with high blood pressure and assessed the bivariate association between HCC stages and participant characteristics and their effect sizes. We used binary and multivariable logistic regression to identify predictors of hypertension screening. Results Eighty-eight per cent of participants reported prior screening for hypertension. However, only 53.5% of patients under pharmacological treatment for hypertension had controlled blood pressure. In bivariate regression, employed participants were 80.3% (COR = 0.197, 95% CI [0.042–0.921]) more likely to be screened. In multivariable regression, the likelihood of hypertension screening was 82.4% (AOR = 0.176, 95% CI [0.047–0.655]) lower among participants in a cohabiting union than single participants. Similarly, employed participants were 87.4% (AOR = 0.129, 95% CI [0.017–0.952]) less likely to be screened than their unemployed counterparts. Conclusions The considerable attrition from the HCC across socio-demographic categories indicates a need for community-wide interventions. Empowering health care workers for community-based health promotion and hypertension management through point-of-care diagnostic tools could improve HCC performance. Efforts to improve the HCC should also focus on social determinants of health, notably gender and formal educational attainment.
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Affiliation(s)
- Herbert Chikafu
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Moses Chimbari
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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18
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Steinert JI, Khan S, Mafara E, Wong C, Mlambo K, Hettema A, Walsh FJ, Lejeune C, Mazibuko S, Okello V, Ogbuoji O, De Neve JW, Vollmer S, Bärnighausen T, Geldsetzer P. The Impact of Immediate Initiation of Antiretroviral Therapy on Patients' Healthcare Expenditures: A Stepped-Wedge Randomized Trial in Eswatini. AIDS Behav 2021; 25:3194-3205. [PMID: 33834318 PMCID: PMC8416844 DOI: 10.1007/s10461-021-03241-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 11/26/2022]
Abstract
Immediate initiation of antiretroviral therapy (ART) for all people living with HIV has important health benefits but implications for the economic aspects of patients' lives are still largely unknown. This stepped-wedge cluster-randomized controlled trial aimed to determine the causal impact of immediate ART initiation on patients’ healthcare expenditures in Eswatini. Fourteen healthcare facilities were randomly assigned to transition at one of seven time points from the standard of care (ART eligibility below a CD4 count threshold) to the immediate ART for all intervention (EAAA). 2261 patients living with HIV were interviewed over the study period to capture their past-year out-of-pocket healthcare expenditures. In mixed-effects regression models, we found a 49% decrease (RR 0.51, 95% CI 0.36, 0.72, p < 0.001) in past-year total healthcare expenditures in the EAAA group compared to the standard of care, and a 98% (RR 0.02, 95% CI 0.00, 0.02, p < 0.001) decrease in spending on private and traditional healthcare. Despite a higher frequency of HIV care visits for newly initiated ART patients, immediate ART initiation appears to have lowered patients’ healthcare expenditures because they sought less care from alternative healthcare providers. This study adds an important economic argument to the World Health Organization’s recommendation to abolish CD4-count-based eligibility thresholds for ART.
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Affiliation(s)
- Janina I Steinert
- TUM School of Governance, Technical University of Munich, Munich, Germany.
| | | | - Emma Mafara
- Clinton Health Acccess Initiative, Boston, USA
| | - Cebele Wong
- Clinton Health Acccess Initiative, Boston, USA
| | | | | | | | | | | | - Velephi Okello
- Ministry of Health of the Kingdom of Eswatini, Mbabane, Eswatini
| | - Osondu Ogbuoji
- Duke Global Health Institute, Duke University, Durham, USA
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Sebastian Vollmer
- Chair of Development Economics, University of Göttingen, Göttingen, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Pascal Geldsetzer
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, USA
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19
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Jockers D, Langlotz S, French D, Bärnighausen T. HIV treatment and worker absenteeism: Quasi-experimental evidence from a large-scale health program in South Africa. JOURNAL OF HEALTH ECONOMICS 2021; 79:102479. [PMID: 34438129 DOI: 10.1016/j.jhealeco.2021.102479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/14/2021] [Accepted: 05/19/2021] [Indexed: 06/13/2023]
Abstract
Over the past decade, large-scale HIV antiretroviral therapy (ART) programs have proven hugely successful in improving the life expectancy of people living with HIV. However, the extent to which treatment allows patients to maintain a productive work life remains an open question. We applied an instrumental variable method based on individual CD4 counts and exogenously changing treatment guidelines to identify the causal effect of ART on health-related absenteeism rates among workers living with HIV. We used monthly data from the occupational health program of one of the world's largest mining companies in South Africa (128,052 observations among 1,924 workers, from 2009 to 2017). Eighteen months after ART initiation, the treatment significantly reduced absenteeism by 1.033 days per worker and month. Using publicly available wage and treatment cost data, we find that the cost savings due to the absenteeism effect of ART alone outweigh treatment costs in the mining sector in several sub-Saharan African countries.
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Affiliation(s)
- Dominik Jockers
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Sarah Langlotz
- Faculty of Business and Economics, University of Goettingen, Goettingen, Germany
| | - Declan French
- Queen's Management School, Queen's University Belfast, Belfast, United Kingdom.
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany; Africa Health Research Institute (AHRI), Somkhele and Durban, South Africa; Harvard Center for Population and Development Studies, Harvard University, Boston, United States
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Okere NE, Sambu V, Ndungile Y, van Praag E, Hermans S, Naniche D, de Wit TFR, Maokola W, Gomez GB. The Shinyanga Patient: A Patient's Journey through HIV Treatment Cascade in Rural Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8418. [PMID: 34444166 PMCID: PMC8393654 DOI: 10.3390/ijerph18168418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/23/2021] [Accepted: 08/04/2021] [Indexed: 12/30/2022]
Abstract
The 2016-2017 Tanzania HIV Impact Survey (THIS) reported the accomplishments towards the 90-90-90 global HIV targets at 61-94-87, affirming the need to focus on the first 90 (i.e., getting 90% of people living with HIV (PLHIV) tested). We conducted a patient-pathway analysis to understand the gap observed, by assessing the alignment between where PLHIV seek healthcare and where HIV services are available in the Shinyanga region, Tanzania. We used existing and publicly available data from the National AIDS Control program, national surveys, registries, and relevant national reports. Region-wide, the majority (n = 458/722, 64%) of THIS respondents accessed their last HIV test at public sector facilities. There were 65.9%, 45.1%, and 74.1% who could also access antiretroviral therapy (ART), CD4 testing, and HIV viral load testing at the location of their last HIV test, respectively. In 2019, the viral suppression rate estimated among PLHIV on ART in the Shinyanga region was 91.5%. PLHIV access HIV testing mostly in public health facilities; our research shows that synergies can be achieved to improve access to services further down the cascade in this sector. Furthermore, effective engagement with the private sector (not-for-profit and for-profit) will help to achieve the last mile toward ending the HIV epidemic.
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Affiliation(s)
- Nwanneka E Okere
- Department of Global Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.H.); (T.F.R.d.W.)
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Veryeh Sambu
- National AIDS Control Programme, Dodoma 41110, Tanzania; (V.S.); (W.M.)
| | - Yudas Ndungile
- Regional Health Management Team, Shinyanga 37103, Tanzania;
| | - Eric van Praag
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Sabine Hermans
- Department of Global Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.H.); (T.F.R.d.W.)
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Denise Naniche
- ISGlobal-Barcelona Institute for Global Health, Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain;
| | - Tobias F Rinke de Wit
- Department of Global Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.H.); (T.F.R.d.W.)
- Amsterdam Institute for Global Health and Development, 1105 BP Amsterdam, The Netherlands;
| | - Werner Maokola
- National AIDS Control Programme, Dodoma 41110, Tanzania; (V.S.); (W.M.)
| | - Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
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Mee P, Rice B, Kabudula CW, Tollman SM, Gómez-Olivé FX, Reniers G. The impact of HIV status on the distance traveled to health facilities and adherence to care. A record-linkage study from rural South Africa. J Glob Health 2021; 10:020435. [PMID: 33312502 PMCID: PMC7719896 DOI: 10.7189/jogh.10.020435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background For people living with HIV (PLWH), the burden of travelling to a clinic outside of one’s home community in order to reduce the level of stigma experienced, may impact adherence to treatment and accelerate disease progression. Methods This study is set in the Agincourt Health and Demographic Surveillance System (HDSS) in South Africa. Probabilistic and interactive methods were used to individually link HDSS data with medical records. A regression analysis was used to assess whether travel distance was correlated with the condition for which individuals were seeking care (primarily HIV, diabetes or hypertension). For PLWH, a Cox proportional hazard regression model was used to test for an association between the distance travelled to the clinic and late attendance at follow-up visits. Results The adjusted relative risk (RR) of travelling to a clinic more than 5 km from that nearest to their home for HIV patients compared to those being treated for other conditions was 2.78 (95% confidence interval (CI) = 2.23-3.48). The adjusted Cox regression model showed no evidence for an association between the distance travelled to a clinic and the rate of late visits. (RR = 1.00, 95% CI = 0.99-1.00). Conclusions The findings were consistent with the hypothesis that people living with HIV/AIDS would be willing to accept the burden of increased clinic travel distances in order to maintain anonymity and so limit their exposure to stigma from fellow community members. For those seeking HIV care the lack of an association between increased travel distances and late visit attendance suggests this may not impact treatment outcomes.
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Affiliation(s)
- Paul Mee
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK.,The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK.,Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Brian Rice
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK.,Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Chodziwadziwa Whiteson Kabudula
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,INDEPTH Network, Accra, Ghana
| | - Stephen M Tollman
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,INDEPTH Network, Accra, Ghana
| | - Francesc Xavier Gómez-Olivé
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,INDEPTH Network, Accra, Ghana
| | - Georges Reniers
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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22
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Stelmach RD, Rabkin M, Abo K, Ahoba I, Gildas Anago M, Boccanera R, Brou H, Flueckiger R, Hartsough K, Msukwa M, Zech J, Young F, Nugent R. Financial burdens of HIV and chronic disease on people living with HIV in Côte d'Ivoire: A cross-sectional out-of-pocket expenditure study. PLoS One 2021; 16:e0255074. [PMID: 34324545 PMCID: PMC8320983 DOI: 10.1371/journal.pone.0255074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/11/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Although people living with HIV in Côte d'Ivoire receive antiretroviral therapy (ART) at no cost, other out-of-pocket (OOP) spending related to health can still create a barrier to care. METHODS A convenience sample of 400 adults living with HIV for at least 1 year in Côte d'Ivoire completed a survey on their health spending for HIV and chronic non-communicable diseases (NCDs). In addition to descriptive statistics, we performed simple linear regression analyses with bootstrapped 95% confidence intervals. FINDINGS 365 participants (91%) reported OOP spending for HIV care, with a median of $16/year (IQR 5-48). 34% of participants reported direct costs with a median of $2/year (IQR 1-41). No participants reported user fees for HIV services. 87% of participants reported indirect costs, with a median of $17/year (IQR 7-41). 102 participants (26%) reported at least 1 NCD. Of these, 80 (78%) reported OOP spending for NCD care, with a median of $50/year (IQR 6-107). 76 participants (95%) with both HIV and NCDs reported direct costs, and 48% reported paying user fees for NCD services. Participants had missed a median of 2 HIV appointments in the past year (IQR 2-3). Higher OOP costs were not associated with the number of HIV appointments missed. 21% of participants reported spending over 10% of household income on HIV and/or NCD care. DISCUSSION AND CONCLUSIONS Despite the availability of free ART, most participants reported OOP spending. OOP costs were much higher for participants with co-morbid NCDs.
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Affiliation(s)
| | - Miriam Rabkin
- ICAP at Columbia University, New York, NY, United States of America
| | - Kouame Abo
- Programme National de Lutte Contre le SIDA (PNLS), Abidjan, Côte d’Ivoire
| | - Irma Ahoba
- Programme National de Lutte Contre le SIDA (PNLS), Abidjan, Côte d’Ivoire
| | | | - Rodrigo Boccanera
- Health Resources and Services Administration, Rockville, MD, United States of America
| | - Hermann Brou
- ICAP at Columbia University, New York, NY, United States of America
| | | | - Kieran Hartsough
- ICAP at Columbia University, New York, NY, United States of America
| | - Martin Msukwa
- ICAP at Columbia University, New York, NY, United States of America
| | - Jennifer Zech
- ICAP at Columbia University, New York, NY, United States of America
| | | | - Rachel Nugent
- RTI International, Seattle, WA, United States of America
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23
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O'Laughlin KN, Greenwald K, Rahman SK, Faustin ZM, Ashaba S, Tsai AC, Ware NC, Kambugu A, Bassett IV. A Social-Ecological Framework to Understand Barriers to HIV Clinic Attendance in Nakivale Refugee Settlement in Uganda: a Qualitative Study. AIDS Behav 2021; 25:1729-1736. [PMID: 33263892 PMCID: PMC8081685 DOI: 10.1007/s10461-020-03102-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/21/2022]
Abstract
The social-ecological model proposes that efforts to modify health behaviors are influenced by constraints and facilitators at multiple levels. We conducted semi-structured interviews with 47 clients in HIV care and 8 HIV clinic staff to explore how such constraints and facilitators (individual, social environment, physical environment, and policies) affect engaging in HIV clinical care in Nakivale Refugee Settlement in Uganda. Thematic analysis revealed that participants were motivated to attend the HIV clinic because of the perceived quality of services and the belief that antiretroviral therapy improves health. Barriers to clinic attendance included distance, cost, unemployment, and climate. Those that disclosed their status had help in overcoming barriers to HIV care. Nondisclosure and stigma disrupted community support in overcoming these obstacles. Interventions to facilitate safe disclosure, mobilize social support, and provide more flexible HIV services may help overcome barriers to HIV care in this setting.
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Affiliation(s)
- Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Kelsy Greenwald
- Harvard Affiliated Emergency Medicine Residency, Boston, MA, USA
| | | | | | | | - Alexander C Tsai
- Mbarara University of Science and Technology, Mbarara, Uganda
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Norma C Ware
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew Kambugu
- Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Ingrid V Bassett
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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24
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Okere NE, Corball L, Kereto D, Hermans S, Naniche D, Rinke de Wit TF, Gomez GB. Patient-incurred costs in a differentiated service delivery club intervention compared to standard clinical care in Northwest Tanzania. J Int AIDS Soc 2021; 24:e25760. [PMID: 34164916 PMCID: PMC8222647 DOI: 10.1002/jia2.25760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Placing all clients with a positive diagnosis for HIV on antiretroviral therapy (ART) has cost implications both for patients and health systems, which could, in turn, affect feasibility, sustainability and uptake of new services. Patient-incurred costs are recognized barriers to healthcare access. Differentiated service delivery (DSD) models in general and community-based care in particular, could reduce these costs. We aimed to assess patient-incurred costs of a community-based DSD intervention (clubs) compared to clinic-based care in the Shinyanga region, Tanzania. METHODS Cross-sectional survey among stable ART patients (n = 390, clinic-based; n = 251, club-based). For each group, we collected socio-demographic, income and expenditure data between May and August 2019. We estimated direct and indirect patient-incurred costs. Direct costs included out-of-pocket expenditures. Indirect costs included income loss due to time spent during transport, accessing services and off work during illness. Cost drivers were assessed in multivariate regression models. RESULTS Overall, costs were significantly higher among clinic participants. Costs (USD) per year for clinic versus club were as follows: 11.7 versus 4.17 (p < 0.001) for direct costs, 20.9 versus 8.23 (p < 0.001) for indirect costs and 32.2 versus 12.4 (p < 0.001) for total costs. Time spent accessing care and time spent in illness (hours/year) were 38.3 versus 13.8 (p < 0.001) and 16.0 versus 6.69 (p < 0.001) respectively. The main cost drivers included transportation (clinic vs. club: 67.7% vs. 44.1%) for direct costs and income loss due to time spent accessing care (clinic vs. club: 60.4% vs. 56.7%) for indirect costs. Factors associated with higher total costs among patients attending clinic services were higher education level (coefficient [95% confidence interval]) 20.9 [5.47 to 36.3]) and formal employment (44.2 [20.0 to 68.5). Differences in mean total costs remained significantly higher with formal employment, rural residence, in addition to more frequent visits among clinic participants. The percentage of households classified as having had catastrophic expenditures in the last year was low but significantly higher among clinic participants (10.8% vs. 5.18%, p = 0.014). CONCLUSIONS Costs incurred by patients accessing DSD in the community are significantly lower compared to those accessing standard clinic-based care. DSD models could improve access, especially in resource-limited settings.
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Affiliation(s)
- Nwanneka E Okere
- Amsterdam Institute for Global Health and DevelopmentDepartment of Global HealthAmsterdam UMCUniversity of AmsterdamAmsterdamNetherlands
| | - Lucia Corball
- Amsterdam Institute for Global Health and DevelopmentDepartment of Global HealthAmsterdam UMCUniversity of AmsterdamAmsterdamNetherlands
| | | | - Sabine Hermans
- Amsterdam Institute for Global Health and DevelopmentDepartment of Global HealthAmsterdam UMCUniversity of AmsterdamAmsterdamNetherlands
| | - Denise Naniche
- ISGLOBAL‐Barcelona Institute for Global HealthHospital ClinicUniversity of BarcelonaBarcelonaSpain
| | - Tobias F Rinke de Wit
- Amsterdam Institute for Global Health and DevelopmentDepartment of Global HealthAmsterdam UMCUniversity of AmsterdamAmsterdamNetherlands
| | - Gabriela B Gomez
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
- Present address:
Vaccine epidemiology and modelling DepartmentSanofi PasteurLyonFrance
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25
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Martin K, Roper T, Vera JH. Point-of-care testing for sexually transmitted infections in low- and middle-income countries: a scoping review protocol. JBI Evid Synth 2021; 19:155-162. [PMID: 32813408 DOI: 10.11124/jbisrir-d-19-00381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE This review will explore how point-of-care tests for sexually transmitted infections have been implemented into health care systems in low- and middle-income countries, and the facilitators and barriers to implementation. INTRODUCTION Sexually transmitted infections contribute to significant global morbidity. In low- and middle-income countries, syndromic management of sexually transmitted infections is recommended. However, due to the limitations of syndromic management, there is increasing interest in the potential for point-of-care tests to be incorporated into models of care for sexually transmitted infections in low-resource settings. It is therefore important to explore how point-of-care tests for sexually transmitted infections have been used in these settings previously, and the facilitators and barriers to implementation on a wider scale. INCLUSION CRITERIA This scoping review will consider studies that explore the use of point-of-care-testing for chlamydia, gonorrhea, trichomoniasis, or syphilis, and how they are implemented into models of care in low- and middle-income countries. Study participants may be those receiving sexually transmitted infection testing or health care professionals providing testing. HIV testing will not be covered. Quantitative, qualitative, and mixed methods study designs, as well as review papers will be considered for inclusion. METHODS The proposed scoping review will be conducted in accordance with JBI methodology for scoping reviews. The authors will search databases including MEDLINE, Embase, Emcare, CINAHL, Scopus, LILACS, African Index Medicus, and the Cochrane library from 1998 onwards. Results will be screened by two independent reviewers and data extracted using a data extraction tool developed by the reviewers. Data will be presented both narratively and in tabular form.
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Affiliation(s)
- Kevin Martin
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK.,Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Tom Roper
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jaime H Vera
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK.,Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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26
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Nichols BE, Cele R, Lekodeba N, Tukei B, Ngorima-Mabhena N, Tiam A, Maotoe T, Sejana MV, Faturiyele IO, Chasela C, Rosen S, Fatti G. Economic evaluation of differentiated service delivery models for HIV treatment in Lesotho: costs to providers and patients. J Int AIDS Soc 2021; 24:e25692. [PMID: 33838012 PMCID: PMC8035675 DOI: 10.1002/jia2.25692] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 01/25/2021] [Accepted: 02/23/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Lesotho, the country with the second-highest HIV/AIDS prevalence (23.6%) in the world, has made considerable progress towards achieving the "95-95-95" UNAIDS targets, but recent success in improving treatment access to all known HIV positive individuals has severely strained existing healthcare infrastructure, financial and human resources. Lesotho also faces the challenge of a largely rural population who incur a significant time and financial burden to visit healthcare facilities. Using data from a cluster-randomized non-inferiority trial conducted between August 2017 and July 2019, we evaluated costs to providers and costs to patients of community-based differentiated models of multi-month delivery of antiretroviral therapy (ART) in Lesotho. METHODS The trial of multi-month dispensing compared 12-month retention in care among three arms: conventional care, which required quarterly facility visits and ART dispensation (3MF); three-month community adherence groups (CAGs) (3MC) and six-month community ART distribution (6MCD). We first estimated the average total annual cost of providing HIV care and treatment followed by the total cost per patient retained 12 months after entry for each arm, using resource utilization data from the trial and local unit costs. We then estimated the average annual cost to patients in each arm with self-reported questionnaire data. RESULTS The average total annual cost of providing HIV care and treatment per patient was the highest in the 3MF arm ($122.28, standard deviation [SD] $23.91), followed by 3MC ($114.20, SD $23.03) and the 6MCD arm ($112.58, SD $21.44). Per patient retained in care, the average provider cost was $125.99 (SD $24.64) in the 3MF arm and 6% to 8% less for the other two arms ($118.38, SD $23.87 and $118.83, SD $22.63 for the 3MC and 6MCD respectively). There was a large reduction in patient costs for both differentiated service delivery arms: from $44.42 (SD $12.06) annually in the 3MF arm to $16.34 (SD $5.11) annually in the 3MC (63% reduction) and $18.77 (SD $8.31) annually in 6MCD arm (58% reduction). CONCLUSIONS Community-based, multi-month models of ART in Lesotho are likely to produce small cost savings to treatment providers and large savings to patients in Lesotho. Patient cost savings may support long-term adherence and retention in care.
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Affiliation(s)
- Brooke E Nichols
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Refiloe Cele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkgomeleng Lekodeba
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Betty Tukei
- Right to Care, Centurion, South Africa.,EQUIP Lesotho, Maseru, Lesotho
| | | | | | | | | | - Iyiola O Faturiyele
- Department of Epidemiology & Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Chasela
- Right to Care, Centurion, South Africa.,USAID, Washington DC, USA
| | - Sydney Rosen
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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27
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McIntosh A, Bachmann M, Siedner MJ, Gareta D, Seeley J, Herbst K. Effect of COVID-19 lockdown on hospital admissions and mortality in rural KwaZulu-Natal, South Africa: interrupted time series analysis. BMJ Open 2021; 11:e047961. [PMID: 33737445 PMCID: PMC7977076 DOI: 10.1136/bmjopen-2020-047961] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/30/2021] [Accepted: 02/22/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To assess the effect of lockdown during the 2020 COVID-19 pandemic on daily all-cause admissions, and by age and diagnosis subgroups, and the odds of all-cause mortality in a hospital in rural KwaZulu-Natal (KZN). DESIGN Observational cohort. SETTING Referral hospital for 17 primary care clinics in uMkhanyakude District. PARTICIPANTS Data collected by the Africa Health Research Institute on all admissions from 1 January to 20 October: 5848 patients contributed to 6173 admissions. EXPOSURE Five levels of national lockdown in South Africa from 27 March 2020, with restrictions decreasing from levels 5 to 1, respectively. OUTCOME MEASURES Changes and trends in daily all-cause admissions and risk of in-hospital mortality before and at each stage of lockdown, estimated by Poisson and logistic interrupted time series regression, with stratification for age, sex and diagnosis. RESULTS Daily admissions decreased during level 5 lockdown for infants (incidence rate ratio (IRR) compared with prelockdown 0.63, 95% CI 0.44 to 0.90), children aged 1-5 years old (IRR 0.43, 95% CI 028 to 0.65) and respiratory diagnoses (IRR 0.57, 95% CI 0.36 to 0.90). From level 4 to level 3, total admissions increased (IRR 1.17, 95% CI 1.06 to 1.28), as well as for men >19 years (IRR 1.50, 95% CI 1.17 to 1.92) and respiratory diagnoses (IRR 4.26, 95% CI 2.36 to 7.70). Among patients admitted to hospital, the odds of death decreased during level 5 compared with prelockdown (adjusted OR 0.48, 95% CI 0.28 to 0.83) and then increased in later stages. CONCLUSIONS Level 5 lockdown is likely to have prevented the most vulnerable population, children under 5 years and those more severely ill from accessing hospital care in rural KZN, as reflected by the drop in admissions and odds of mortality. Subsequent increases in admissions and in odds of death in the hospital could be due to improved and delayed access to hospital as restrictions were eased.
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Affiliation(s)
- Amy McIntosh
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Max Bachmann
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- DSI-MRC South African Population Research Infrastructure Network, Durban, South Africa
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28
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Geldsetzer P, Sauer A, Francis JM, Mboggo E, Lwezaula S, Sando D, Fawzi W, Ulenga N, Bärnighausen T. Willingness to pay for community delivery of antiretroviral treatment in urban Tanzania: a cross-sectional survey. Health Policy Plan 2021; 35:1300-1308. [PMID: 33083837 PMCID: PMC7886440 DOI: 10.1093/heapol/czaa088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 11/23/2022] Open
Abstract
Community health worker (CHW)-led community delivery of HIV antiretroviral therapy (ART) could increase ART coverage and decongest healthcare facilities. It is unknown how much patients would be willing to pay to receive ART at home and, thus, whether ART community delivery could be self-financing. Set in Dar es Salaam, this study aimed to determine patients' willingness to pay (WTP) for CHW-led ART community delivery. We sampled ART patients living in the neighbourhoods surrounding each of 48 public-sector healthcare facilities in Dar es Salaam. We asked participants (N = 1799) whether they (1) preferred ART community delivery over standard facility-based care, (2) would be willing to pay for ART community delivery and (3) would be willing to pay each of an incrementally increasing range of prices for the service. 45.0% (810/1799; 95% CI: 42.7-47.3) of participants preferred ART community delivery over standard facility-based care and 51.5% (417/810; 95% CI: 48.1-55.0) of these respondents were willing to pay for ART community delivery. Among those willing to pay, the mean and median amount that participants were willing to pay for one ART community delivery that provides a 2-months' supply of antiretroviral drugs was 3.61 purchasing-power-parity-adjusted dollars (PPP$) (95% CI: 2.96-4.26) and 1.27 PPP$ (IQR: 1.27-2.12), respectively. An important limitation of this study is that participants all resided in neighbourhoods within the catchment area of the healthcare facility at which they were interviewed and, thus, may incur less costs to attend standard facility-based ART care than other ART patients in Dar es Salaam. While there appears to be a substantial WTP, patient payments would only constitute a minority of the costs of implementing ART community delivery. Thus, major co-financing from governments or donors would likely be required.
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Affiliation(s)
- Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA 94305, USA
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Alexander Sauer
- Department of Statistics, University of Oxford, 24-29 St Giles', Oxford OX1 3LB, UK
| | - Joel M Francis
- Department of Family Medicine and Primary Care, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Eric Mboggo
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Sharon Lwezaula
- National AIDS Control Program, Lithuli Street, Dar es Salaam, P.O. Box 11857, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
| | - Nzovu Ulenga
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Africa Health Research Institute (AHRI), Africa Centre Building, Via R618 to Hlabisa, Somkhele, P.O. Box 198, Mtubatuba 3935, South Africa
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29
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Predictors of suboptimal adherence to isoniazid preventive therapy among adolescents and children living with HIV. PLoS One 2020; 15:e0243713. [PMID: 33332462 PMCID: PMC7746166 DOI: 10.1371/journal.pone.0243713] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/26/2020] [Indexed: 01/15/2023] Open
Abstract
This study identified factors associated with adherence to a 6-month isoniazid preventive therapy (IPT) course among adolescents and children living with HIV. Forty adolescents living with HIV and 48 primary caregivers of children living with HIV completed a Likert-based survey to measure respondent opinions regarding access to care, quality of care, preferred regimens, perceived stigma, and confidence in self-efficacy. Sociodemographic data were collected and adherence measured as the average of pill counts obtained while on IPT. The rates of suboptimal adherence (< 95% adherent) were 22.5% among adolescents and 37.5% among the children of primary caregivers. Univariate logistic regression was used to model the change in the odds of suboptimal adherence. Independent factors associated with suboptimal adherence among adolescents included age, education level, the cost of coming to clinic, stigma from community members, and two variables relating to self-efficacy. Among primary caregivers, child age, concerns about stigma, and location preference for meeting a community-health worker were associated with suboptimal adherence. To determine whether these combined factors contributed different information to the prediction of suboptimal adherence, a risk score containing these predictors was constructed for each group. The risk score had an AUC of 0.87 (95% CI: 0.76, 0.99) among adolescents and an AUC of 0.76 (95% CI: 0.62, 0.90), among primary caregivers suggesting that these variables may have complementary predictive utility. The heterogeneous scope and associations of these variables in different populations suggests that interventions aiming to increase optimal adherence will need to be tailored to specific populations and multifaceted in nature. Ideally interventions should address both long-established barriers to adherence such as cost of transportation to attend clinic and more nuanced psychosocial barriers such as perceived community stigma and confidence in self-efficacy.
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Odland ML, Bockarie T, Wurie H, Ansumana R, Lamin J, Nugent R, Bakolis I, Witham M, Davies J. Prevalence and access to care for cardiovascular risk factors in older people in Sierra Leone: a cross-sectional survey. BMJ Open 2020; 10:e038520. [PMID: 32907906 PMCID: PMC7482482 DOI: 10.1136/bmjopen-2020-038520] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Prevalence of cardiovascular disease risk factors (CVDRFs) is increasing, especially in low-income countries. In Sierra Leone, there is limited empirical data on the prevalence of CVDRFs, and there are no previous studies on the access to care for these conditions. METHODS This study in rural and urban Sierra Leone collected demographic, anthropometric measurements and clinical data from randomly sampled individuals over 40 years old using a household survey. We describe the prevalence of the following risk factors: diabetes, hypertension, dyslipidaemia, overweight or obesity, smoking and having at least one of these risk factors. Cascades of care were constructed for diabetes and hypertension using % of the population with the disease who had previously been tested ('screened'), knew of their condition ('diagnosed'), were on treatment ('treated') or were controlled to target ('controlled'). Multivariable regression was used to test associations between prevalence of CVDRFs and progress through the cascade for hypertension with demographic and socioeconomic variables. In those with recognised disease who did not seek care, reasons for not accessing care were recorded. RESULTS Of 2071 people, 49.6% (95% CI 49.3% to 50.0%) of the population had hypertension, 3.5% (3.4% to 3.6%) had diabetes, 6.7% (6.5% to 7.0%) had dyslipidaemia, 25.6% (25.4% to 25.9%) smoked and 26.5% (26.3% to 26.8%) were overweight/obese; a total of 77.1% (76.6% to 77.5%) had at least one CVDRF. People in urban areas were more likely to have diabetes and be overweight than those living in rural areas. Moreover, being female, more educated or wealthier increased the risk of having all CVDRFs except for smoking. There is a substantial loss of patients at each step of the care cascade for both diabetes and hypertension, with less than 10% of the total population with the conditions being screened, diagnosed, treated and controlled. The most common reasons for not seeking care were lack of knowledge and cost. CONCLUSIONS In Sierra Leone, CVDRFs are prevalent and access to care is low. Health system strengthening with a focus on increased access to quality care for CVDRFs is urgently needed.
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Affiliation(s)
- Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Tahir Bockarie
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Rashid Ansumana
- Mercy Hospital Research Laboratory, Bo, Sierra Leone
- School of Community Health Sciences, Njala University, Bo Campus, Bo, Sierra Leone
| | - Joseph Lamin
- Mercy Hospital Research Laboratory, Bo, Sierra Leone
| | | | - Ioannis Bakolis
- Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Miles Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, Newcastle upon Tyne, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
- Centre for Global Surgery, Department for Global Health, Stellenbosch University, Stellenbosch, South Africa
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Steinert JI, Khan S, Mlambo K, Walsh FJ, Mafara E, Lejeune C, Wong C, Hettema A, Ogbuoji O, Vollmer S, De Neve JW, Mazibuko S, Okello V, Bärnighausen T, Geldsetzer P. A stepped-wedge randomised trial on the impact of early ART initiation on HIV-patients' economic outcomes in Eswatini. eLife 2020; 9:58487. [PMID: 32831169 PMCID: PMC7529454 DOI: 10.7554/elife.58487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/21/2020] [Indexed: 12/12/2022] Open
Abstract
Background Since 2015, the World Health Organisation (WHO) recommends immediate initiation of antiretroviral therapy (ART) for all HIV-positive patients. Epidemiological evidence points to important health benefits of immediate ART initiation; however, the policy’s impact on the economic aspects of patients' lives remains unknown. Methods We conducted a stepped-wedge cluster-randomised controlled trial in Eswatini to determine the causal impact of immediate ART initiation on patients’ individual- and household-level economic outcomes. Fourteen healthcare facilities were non-randomly matched into pairs and then randomly allocated to transition from the standard of care (ART eligibility at CD4 counts of <350 cells/mm3 until September 2016 and <500 cells/mm3 thereafter) to the ‘Early Initiation of ART for All’ (EAAA) intervention at one of seven timepoints. Patients, healthcare personnel, and outcome assessors remained unblinded. Data were collected via standardised paper-based surveys with HIV-positive adults who were neither pregnant nor breastfeeding. Outcomes were patients’ time use, employment status, household expenditures, and household living standards. Results A total sample of 3019 participants were interviewed over the duration of the study. The mean number of participants approached at each facility per time step varied from 4 to 112 participants. Using mixed-effects negative binomial regressions accounting for time trends and clustering at the level of the healthcare facility, we found no significant difference between study arms for any economic outcome. Specifically, the EAAA intervention had no significant effect on non-resting time use (RR = 1.00 [CI: 0.96, 1.05, p=0.93]) or income-generating time use (RR = 0.94, [CI: 0.73,1.20, p=0.61]). Employment and household expenditures decreased slightly but not significantly in the EAAA group, with risk ratios of 0.93 [CI: 0.82, 1.04, p=0.21] and 0.92 [CI: 0.79, 1.06, p=0.26], respectively. We also found no significant treatment effect on households’ asset ownership and living standards (RR = 0.96, [CI 0.92, 1.00, p=0.253]). Lastly, there was no evidence of heterogeneity in effect estimates by patients’ sex, age, education, timing of HIV diagnosis and ART initiation. Conclusions Our findings do not provide evidence that should discourage further investments into scaling up immediate ART for all HIV patients. Funding Funded by the Dutch Postcode Lottery in the Netherlands, Alexander von Humboldt-Stiftung (Humboldt-Stiftung), the Embassy of the Kingdom of the Netherlands in South Africa/Mozambique, British Columbia Centre of Excellence in Canada, Doctors Without Borders (MSF USA), National Center for Advancing Translational Sciences of the National Institutes of Health and Joachim Herz Foundation. Clinical trial number NCT02909218 and NCT03789448.
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Affiliation(s)
| | - Shaukat Khan
- Clinton Health Acccess Initiative, Boston, United States
| | - Khudzie Mlambo
- Clinton Health Acccess Initiative, Boston, United States
| | - Fiona J Walsh
- Clinton Health Acccess Initiative, Boston, United States
| | - Emma Mafara
- Clinton Health Acccess Initiative, Boston, United States
| | | | - Cebele Wong
- Clinton Health Acccess Initiative, Boston, United States
| | - Anita Hettema
- Clinton Health Acccess Initiative, Boston, United States
| | - Osondu Ogbuoji
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, United States
| | | | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | | | - Velephi Okello
- Ministry of Health of the Kingdom of Eswatini, Mbabane, Eswatini
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Pascal Geldsetzer
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany.,Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, United States
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32
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Nanfuka EK, Kyaddondo D, Ssali SN, Asingwire N. Paying to Normalize Life: Monetary and Psychosocial Costs of Realizing a Normal Life in the Context of Free Antiretroviral Therapy Services in Uganda. J Int Assoc Provid AIDS Care 2020; 18:2325958219859654. [PMID: 31266380 PMCID: PMC6748487 DOI: 10.1177/2325958219859654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Antiretroviral therapy (ART) is considered the treatment that enables people living with
HIV (PLHIV) to lead a “normal life”. In spite of the availability of free treatment,
patients in resource-poor settings may continue to incur additional costs to realize a
normal and full life. This article describes the monetary expenses and psychosocial
distress people on free ART bear to live normally. We conducted in-depth interviews with
50 PLHIV on ART. We found that the demands of treatment, poverty, stigma, and
health-system constraints interplay to necessitate that PLHIV bear continuous monetary and
psychosocial costs to realize local values that define normal life. In the context, access
to free medicines is not sufficient to enable PLHIV in resource-poor settings to normalize
life. Policy makers and providers should consider proactively complementing free ART with
mechanisms that empower PLHIV economically, enhance their problem-solving capacities, and
provide an enabling environment if the objective of normalizing life is to be
achieved.
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Affiliation(s)
- Esther Kalule Nanfuka
- 1 Department of Social Work and Social Administration, Makerere University Kampala, Uganda
| | - David Kyaddondo
- 1 Department of Social Work and Social Administration, Makerere University Kampala, Uganda
| | - Sarah N Ssali
- 2 School of Women and Gender Studies, Makerere University Kampala, Uganda
| | - Narathius Asingwire
- 1 Department of Social Work and Social Administration, Makerere University Kampala, Uganda
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Sweeney S, Vassall A, Guinness L, Siapka M, Chimbindi N, Mudzengi D, Gomez GB. Examining Approaches to Estimate the Prevalence of Catastrophic Costs Due to Tuberculosis from Small-Scale Studies in South Africa. PHARMACOECONOMICS 2020; 38:619-631. [PMID: 32239479 PMCID: PMC7307451 DOI: 10.1007/s40273-020-00898-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND OBJECTIVE In context of the End TB goal of zero tuberculosis (TB)-affected households encountering catastrophic costs due to TB by 2020, the estimation of national prevalence of catastrophic costs due to TB is a priority to inform programme design. We explore approaches to estimate the national prevalence of catastrophic costs due to TB from existing datasets as an alternative to nationally representative surveys. METHODS We obtained, standardized and merged three patient-level datasets from existing studies on patient-incurred costs due to TB in South Africa. A deterministic cohort model was developed with the aim of estimating the national prevalence of catastrophic costs, using national data on the prevalence of TB and likelihood of loss to follow-up by income quintile and HIV status. Two approaches were tested to parameterize the model with existing cost data. First, a meta-analysis summarized study-level data by HIV status and income quintile. Second, a regression analysis of patient-level data also included employment status, education level and urbanicity. We summarized findings by type of cost and examined uncertainty around resulting estimates. RESULTS Overall, the median prevalence of catastrophic costs for the meta-analysis and regression approaches were 11% (interquartile range [IQR] 9-13%) and 6% (IQR 5-8%), respectively. Both approaches indicated that the main burden of catastrophic costs falls on the poorest households. An individual-level regression analysis produced lower uncertainty around estimates than a study-level meta-analysis. CONCLUSIONS This paper presents a novel application of existing data to estimate the national prevalence of catastrophic costs due to TB. This type of model could be useful for researchers and policy makers looking to inform certain policy decisions; however, some uncertainties remain due to limitations in data availability. There is an urgent need for standardized reporting of cost data and improved guidance on methods to collect income data to improve these estimates going forward.
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Affiliation(s)
- Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Room 327, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Room 327, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Lorna Guinness
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Room 327, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Mariana Siapka
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Room 327, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | | | | | - Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Room 327, 15-17 Tavistock Place, London, WC1H 9SH, UK
- Vaccine Epidemiology and Modelling, Sanofi Pasteur SA, Lyon, France
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34
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Shin H, Ngwira LG, Tucker A, Chaisson RE, Corbett EL, Dowdy D. Patient-incurred cost of inpatient treatment for Tuberculosis in rural Malawi. Trop Med Int Health 2020; 25:624-634. [PMID: 32034984 PMCID: PMC7658961 DOI: 10.1111/tmi.13381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To mitigate the economic burden of tuberculosis (TB), it is important to fully understand the costs of TB treatment from the patient perspective. We therefore sought to quantify the patient-incurred cost of TB treatment in rural Malawi, with specific focus on costs borne by patients requiring inpatient hospitalisation. METHODS We conducted a cross-sectional survey of 197 inpatients and 156 outpatients being treated for TB in rural Malawi. We collected data on out-of-pocket costs and lost wages, including costs to guardians. Costs for inpatient TB treatment were estimated and compared to costs for outpatient TB treatment. We then explored the equity distribution of inpatient TB treatment cost using concentration curves. RESULTS Despite free government services, inpatients were estimated to incur a mean of $137 (standard deviation: $147) per initial TB episode, corresponding to >50% of annual household spending among patients in the lowest expenditure quintile. Non-medical hospitalisation costs accounted for 88% of this total. Patients treated entirely as outpatients incurred estimated costs of $25 (standard deviation: $15) per episode. The concentration curves showed that, among individuals hospitalised for an initial TB episode, poorer patients shouldered a much greater proportion of inpatient TB treatment costs than wealthier ones (concentration index: -0.279). CONCLUSION Patients hospitalised for TB in resource-limited rural Malawi experience devastating costs of TB treatment. Earlier diagnosis and treatment must be prioritised if we are to meet goals of effective TB control, avoidance of catastrophic costs and provision of appropriate patient-centred care in such settings.
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Affiliation(s)
- Hyejeong Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lucky G. Ngwira
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Sciences Department, Liverpool School of Tropical Medicine, UK
| | - Austin Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Richard E Chaisson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth L Corbett
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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35
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Bor J, Thirumurthy H. Bridging the Efficacy-Effectiveness Gap in HIV Programs: Lessons From Economics. J Acquir Immune Defic Syndr 2019; 82 Suppl 3:S183-S191. [PMID: 31764253 PMCID: PMC7388866 DOI: 10.1097/qai.0000000000002201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bridging the efficacy-effectiveness gap in HIV prevention and treatment requires policies that account for human behavior. SETTING Worldwide. METHODS We conducted a narrative review of the literature on HIV in the field of economics, identified common themes within the literature, and identified lessons for implementation science. RESULTS The reviewed studies illustrate how behaviors are shaped by perceived costs and benefits across a wide range of health and nonhealth domains, how structural constraints shape decision-making, how information interventions can still be effective in the epidemic's fourth decade, and how lessons from behavioral economics can be used to improve intervention effectiveness. CONCLUSION Economics provides theoretical insights and empirical methods that can guide HIV implementation science.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University, Boston, MA
| | - Harsha Thirumurthy
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
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36
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Mokhele I, Mashamaite S, Majuba P, Xulu T, Long L, Onoya D. Effective public-private partnerships for sustainable antiretroviral therapy: outcomes of the Right to Care health services GP down-referral program. BMC Public Health 2019; 19:1471. [PMID: 31699063 PMCID: PMC6836664 DOI: 10.1186/s12889-019-7660-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/20/2019] [Indexed: 11/14/2022] Open
Abstract
Background The recently increased access to antiretroviral therapy (ART) in South Africa has placed additional strain on human and infrastructure resources of the public health sector. Capacity from private-sector General Practitioners (GPs) could be leveraged to ease the current burden on the public health sector. Methods We conducted a retrospective record review of routine electronic medical record data on a systematic sample of HIV-infected adults (≥18 years old) initiated on ART at a tertiary hospital outpatient HIV clinic in Johannesburg, South Africa and down-referred to private-GPs for continued care after stabilization on ART. We compared these patients (“GP down-referred”) to a control-cohort who remained at the referring site (“Clinic A”) and patients from a regional hospital outpatient HIV clinic not offering down-referral to GPs (“Clinic B”). Study outcomes assessed are viral load suppression (VL < 50 copies/ml) and attrition from care (all-cause-mortality or > 90-days late for a last-scheduled visit) by 12 months of follow-up following down-referral or eligibility. Results A total of 3685 patients, comprising 373 (10.1%) GP down-referred, 2599 (70.5%) clinic A controls, and 713 (19.4%) clinic B controls were included in the analysis. Overall, 1535 patients (53.3%) had a suppressed viral load. A higher portion of GP down-referred patients had a suppressed viral load compared to clinic A and B patients (65.7% vs 49.1% vs 58.9%). After adjusting for demographic and baseline clinical covariates, we found no difference in viral load suppression between GP down-referred and control patients (adjusted relative risk [aRR] for clinic A vs GP down-referred 1.0; 95% CI: 0.9–1.1), (aRR for clinic B vs GP down-referred 1.0; 95% CI: 0.9–1.2). Clinic B controls experienced the highest attrition compared to GP down-referred and clinic A controls (33.2% vs 11.3% vs 5.9%) and had a higher risk of attrition compared to GP down-referred patients (adjusted hazard ratio [aHR] 4.2; 95% CI: 2.8–6.5), whereas clinic B controls had a lower risk of attrition (aHR 0.5; 95% CI: 0.3–0.7). Conclusions and recommendations Our results show that private-GPs can contribute to caring for stabilized public sector HIV patients on life-long ART. However, they require special efforts to improve retention in care.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | | | | | | | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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37
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Le Roux KW, Davis EC, Gaunt CB, Young C, Koussa M, Harris C, Rotheram-Borus MJ. A Case Study of an Effective and Sustainable Antiretroviral Therapy Program in Rural South Africa. AIDS Patient Care STDS 2019; 33:466-472. [PMID: 31682167 DOI: 10.1089/apc.2019.0055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The delivery of high-quality HIV care in rural settings is a global challenge. Despite the successful expansion of antiretroviral therapy (ART) in Africa, viral load (VL) monitoring and ART adherence are poor, especially in rural communities. This article describes a case study of an ART program in the deeply rural Eastern Cape of South Africa. The Zithulele ART Program initiated five innovations over time: (1) establishing district hospital as the logistical hub for all ART care in a rural district, (2) primary care clinic delivery of prepackaged ART and chronic medications for people living with HIV (PLH), (3) establishing central record keeping, (4) incentivizing VL monitoring, and (5) providing hospital-based outpatient care for complex cases. Using a pharmacy database, on-time VL monitoring and viral suppression were evaluated for 882 PLH initiating ART in the Zithulele catchment area in 2013. Among PLH initiating ART, 12.5% (n = 110) were lost to follow-up, 7.7% (n = 68) transferred out of the region, 10.2% (n = 90) left the program and came back at a later date, and 4.0% (n = 35) died. Of the on-treatment population, 82.9% (n = 480/579) had VL testing within 7 months and 92.6% (n = 536/579) by 1 year. Viral suppression was achieved in 85.2% of those tested (n = 457/536), or 78.9% (n = 457/579) overall. The program's VL testing and suppression rates appear about twice as high as national data and data from other rural centers in South Africa, despite fewer resources than other programs. Simple system innovations can ensure high rates of VL testing and suppression, even in rural health facilities.
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Affiliation(s)
- Karl W. Le Roux
- Zithulele Hospital, Mqanduli District, South Africa
- Woodrow Wilson School of Public International Affairs at Princeton University, Princeton, New Jersey
| | - Emily C. Davis
- Department of Psychiatry, University of California Los Angeles, Los Angeles, California
| | | | - Catherine Young
- Jabulani Rural Health Foundation, Mqanduli District, South Africa
| | - Maryann Koussa
- Department of Psychiatry, University of California Los Angeles, Los Angeles, California
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38
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Hussain H, Mori AT, Khan AJ, Khowaja S, Creswell J, Tylleskar T, Robberstad B. The cost-effectiveness of incentive-based active case finding for tuberculosis (TB) control in the private sector Karachi, Pakistan. BMC Health Serv Res 2019; 19:690. [PMID: 31606031 PMCID: PMC6790051 DOI: 10.1186/s12913-019-4444-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 08/20/2019] [Indexed: 11/26/2022] Open
Abstract
Background In Asia, over 50% of patients with symptoms of tuberculosis (TB) access health care from private providers. These patients are usually not notified to the National TB Control Programs, which contributes to low notification rates in many countries. Methods From January 1, 2011 to December 31, 2012, Karachi’s Indus Hospital - a private sector partner to the National TB Programme - engaged 80 private family clinics in its catchment area in active case finding using health worker incentives to increase notification of TB disease. The costs incurred were estimated from the perspective of patients, health facility and the program providing TB services. A Markov decision tree model was developed to calculate the cost-effectiveness of the active case finding as compared to case detection through the routine passive TB centers. Pakistan has a large private health sector, which can be mobilized for TB screening using an incentivized active case finding strategy. Currently, TB screening is largely performed in specialist public TB centers through passive case finding. Active and passive case finding strategies are assumed to operate independently from each other. Results The incentive-based active case finding program costed USD 223 per patient treated. In contrast, the center based non-incentive arm was 23.4% cheaper, costing USD 171 per patient treated. Cost-effectiveness analysis showed that the incentive-based active case finding program was more effective and less expensive per DALY averted when compared to the baseline passive case finding as it averts an additional 0.01966 DALYs and saved 15.74 US$ per patient treated. Conclusion Both screening strategies appear to be cost-effective in an urban Pakistan context. Incentive driven active case findings of TB in the private sector costs less and averts more DALYs per health seeker than passive case finding, when both alternatives are compared to a common baseline situation of no screening. Electronic supplementary material The online version of this article (10.1186/s12913-019-4444-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hamidah Hussain
- Interactive Research and Development, Global, Singapore, Singapore. .,Centre for International Health, Bergen, Norway. .,Department of Global Public Health and Primary Care,
- University of Bergen, Bergen, Norway.
| | - Amani Thomas Mori
- Centre for International Health, Bergen, Norway.,Department of Global Public Health and Primary Care,
- University of Bergen, Bergen, Norway
| | - Aamir J Khan
- Interactive Research and Development, Global, Singapore, Singapore
| | - Saira Khowaja
- Interactive Research and Development, Global, Singapore, Singapore
| | | | - Thorkild Tylleskar
- Centre for International Health, Bergen, Norway.,Department of Global Public Health and Primary Care,
- University of Bergen, Bergen, Norway
| | - Bjarne Robberstad
- Department of Global Public Health and Primary Care,
- University of Bergen, Bergen, Norway.,Section for Ethics and Health Economics, Bergen, Norway
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39
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Chaudhury S, Hertzmark E, Muya A, Sando D, Ulenga N, Machumi L, Spiegelman D, Fawzi WW. Equity of child and adolescent treatment, continuity of care and mortality, according to age and gender among enrollees in a large HIV programme in Tanzania. J Int AIDS Soc 2019; 21 Suppl 1. [PMID: 29485735 PMCID: PMC5978660 DOI: 10.1002/jia2.25070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 01/18/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction Global scale up of anti‐retroviral therapy (ART) has led to expansion of HIV treatment and prevention across sub‐Saharan Africa. However, age and gender‐specific disparities persist leading to failures in fulfillment of Sustainability Development Goals, including SDG3 (achieving healthy lives and wellbeing for all, at all ages) and SDG5 (gender equality). We assessed ART initiation and adherence, loss to follow‐up, all‐cause death and early death, according to SDG3 and SDG5 indicators among a cohort of HIV‐infected children and adolescents enrolled in care in Dar‐es‐Salaam, Tanzania Methods SDG3 indicators included young (<5 years) and older paediatric children (5 to <10 years), early adolescent (10 to <15 years) and late adolescent (15 to <20 years) age group divisions and the SDG5 indicator was gender. Associations of age group and gender with ART initiation, loss to follow‐up and all‐cause death, were analysed using Cox proportional hazards regression and with adherence, using generalized estimating equations (GEE) with the Poisson distribution. Associations of age group and gender with early death were analysed, using log‐Poisson regression with empirical variance. Results A total of 18,315 enrollees with at least one clinic visit were included in this cohort study. Of these 7238 (40%) were young paediatric , 4169 (23%) older paediatric, 2922 (16%) early adolescent and 3986 (22%) late adolescent patients at enrolment. Just over half of paediatric and early adolescents and around four fifths of the late adolescents were female. Young paediatric patients were at greater risk of early death, being almost twice as likely to die within 90 days. Males were at greater risk of early death once initiated on ART (HR 1.35, 95% CI 1.09, 1.66)), while females in late adolescence were at greatest risk of late death (HR 2.44 [1.60, 3.74] <0.01). Late adolescents demonstrated greater non‐engagement in care (RR 1.21 (95% CI 1.16, 1.26)). Among both males and females, early paediatric and late adolescent groups experienced significantly greater loss to follow‐up. Conclusion These findings highlight equity concerns critical to the fulfillment of SDG3 and SDG5 within services for children and adolescents living with HIV in sub‐Saharan Africa. Young paediatric and late adolescent age groups were at increased risk of late diagnosis, early death, delayed treatment initiation and loss of continuity of care. Males were more likely to die earlier. Special attention to SDG3 and SDG5 disparities for children and adolescents living with HIV will be critical for fulfillment of the 2030 SDG agenda.
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Affiliation(s)
- Sumona Chaudhury
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Aisa Muya
- Management and Development for Health, Dar es Salaam, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA.,Management and Development for Health, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Lameck Machumi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Donna Spiegelman
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Wafaie W Fawzi
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
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Geldsetzer P, Manne-Goehler J, Marcus ME, Ebert C, Zhumadilov Z, Wesseh CS, Tsabedze L, Supiyev A, Sturua L, Bahendeka SK, Sibai AM, Quesnel-Crooks S, Norov B, Mwangi KJ, Mwalim O, Wong-McClure R, Mayige MT, Martins JS, Lunet N, Labadarios D, Karki KB, Kagaruki GB, Jorgensen JMA, Hwalla NC, Houinato D, Houehanou C, Msaidié M, Guwatudde D, Gurung MS, Gathecha G, Dorobantu M, Damasceno A, Bovet P, Bicaba BW, Aryal KK, Andall-Brereton G, Agoudavi K, Stokes A, Davies JI, Bärnighausen T, Atun R, Vollmer S, Jaacks LM. The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults. Lancet 2019; 394:652-662. [PMID: 31327566 DOI: 10.1016/s0140-6736(19)30955-9] [Citation(s) in RCA: 301] [Impact Index Per Article: 60.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/03/2019] [Accepted: 04/09/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs-and its variation between countries and population groups-by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage. METHODS In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval. FINDINGS Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9-74·3) had ever had their blood pressure measured, 39·2% of participants (38·2-40·3) had been diagnosed with hypertension, 29·9% of participants (28·6-31·3) received treatment, and 10·3% of participants (9·6-11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade. INTERPRETATION Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage. FUNDING Harvard McLennan Family Fund, Alexander von Humboldt Foundation.
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Affiliation(s)
- Pascal Geldsetzer
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Jennifer Manne-Goehler
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maja-Emilia Marcus
- Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | - Cara Ebert
- Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany; RWI-Leibniz Institute for Economic Research, Berlin, Germany
| | - Zhaxybay Zhumadilov
- National Laboratory Astana, University Medical Center, Nazarbayev University, Astana, Kazakhstan
| | | | | | - Adil Supiyev
- Laboratory of Epidemiology and Public Health, Center for Life Sciences, Nazarbayev University, Astana, Kazakhstan
| | - Lela Sturua
- Non-Communicable Diseases Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | | | - Abla M Sibai
- Epidemiology and Population Health Department, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Sarah Quesnel-Crooks
- Non-Communicable Diseases, Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago
| | - Bolormaa Norov
- National Center for Public Health, Ulaanbaatar, Mongolia
| | - Kibachio J Mwangi
- Division of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya; The Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Roy Wong-McClure
- Office of Epidemiology and Surveillance, Costa Rican Social Security Fund, San José, Costa Rica
| | - Mary T Mayige
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Joao S Martins
- Faculty of Medicine and Health Sciences, National University of East Timor, Dili, Timor-Leste
| | - Nuno Lunet
- Department of Public and Forensic Health Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Demetre Labadarios
- Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Khem B Karki
- Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | | | - Nahla C Hwalla
- Faculty of Agricultural and Food Sciences, American University of Beirut, American University of Beirut, Beirut, Lebanon
| | - Dismand Houinato
- Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
| | - Corine Houehanou
- Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
| | - Mohamed Msaidié
- Ministry of Health, Solidarity, Social Cohesion and Gender, Government of Comoros, Moroni, Comoros
| | - David Guwatudde
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Mongal S Gurung
- Health Research and Epidemiology Unit, Ministry of Health, Thimphu, Bhutan
| | - Gladwell Gathecha
- Division of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
| | - Maria Dorobantu
- Department of Cardiology, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Albertino Damasceno
- Department of Public and Forensic Health Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal; EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal; Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Pascal Bovet
- Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland; Ministry of Health, Victoria, Seychelles
| | - Brice W Bicaba
- Institut Africain de Santé Publique, Ouagadougou, Burkina Faso
| | - Krishna K Aryal
- Department for International Development/Nepal Health Sector Programme 3/Monitoring Evaluation and Operational Research, Abt Associates, Kathmandu, Nepal
| | - Glennis Andall-Brereton
- Non-Communicable Diseases, Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago
| | | | - Andrew Stokes
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Justine I Davies
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Africa Health Research Institute, Somkhele, South Africa; Heidelberg Institute of Global Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany.
| | - Rifat Atun
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Global Health and Social Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | - Lindsay M Jaacks
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Public Health Foundation of India, New Delhi, Delhi, India
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Amstutz A, Lejone TI, Khesa L, Muhairwe J, Nsakala BL, Tlali K, Bresser M, Tediosi F, Kopo M, Kao M, Klimkait T, Battegay M, Glass TR, Labhardt ND. VIBRA trial - Effect of village-based refill of ART following home-based same-day ART initiation vs clinic-based ART refill on viral suppression among individuals living with HIV: protocol of a cluster-randomized clinical trial in rural Lesotho. Trials 2019; 20:522. [PMID: 31439004 PMCID: PMC6704675 DOI: 10.1186/s13063-019-3510-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 06/10/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND There is a need for evaluating community-based antiretroviral therapy (ART) delivery models to improve overall performance of HIV programs, specifically in populations that may have difficulties to access continuous care. This cluster-randomized clinical trial aims to evaluate the effectiveness of a multicomponent differentiated ART delivery model (VIBRA model) after home-based same-day ART initiation in remote villages in Lesotho, southern Africa. METHODS/DESIGN The VIBRA trial (VIllage-Based Refill of ART) is a cluster-randomized parallel-group superiority clinical trial conducted in two districts in Lesotho, southern Africa. Clusters (i.e., villages) are randomly assigned to either the VIBRA model or standard care. The clusters are stratified by district, village size, and village access to the nearest health facility. Eligible individuals (HIV-positive, aged 10 years or older, and not taking ART) identified during community-based HIV testing campaigns are offered same-day home-based ART initiation. The intervention clusters offer a differentiated ART delivery package with two features: (1) drug refills and follow-ups by trained and supervised village health workers (VHWs) and (2) the option of receiving individually tailored adherence reminders and notifications of viral load results via SMS. The control clusters will continue to receive standard care, i.e., collecting ART refills from a clinic and no SMS notifications. The primary endpoint is viral suppression 12 months after enrolment. Secondary endpoints include linkage to and engagement in care. Furthermore, safety and cost-effectiveness analyses plus qualitative research are planned. The minimum target sample size is 262 participants. The statistical analyses will follow the CONSORT guidelines. The VIBRA trial is linked to another trial, the HOSENG (HOme-based SElf-testiNG) trial, both of which are within the GET ON (GETing tOwards Ninety) research project. DISCUSSION The VIBRA trial is among the first to evaluate the delivery of ART by VHWs immediately after ART initiation. It assesses the entire HIV care cascade from testing to viral suppression. As most countries in sub-Saharan Africa have cadres like the VHW program in Lesotho, this model-if shown to be effective-has the potential to be scaled up. The system impact evaluation will provide valuable cost estimations, and the qualitative research will suggest how the model could be further modified to optimize its impact. TRIAL REGISTRATION Clinicaltrials.gov, NCT03630549 . Registered on 15 August 2018.
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Affiliation(s)
- Alain Amstutz
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland
| | | | - Lefu Khesa
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Josephine Muhairwe
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | | | - Katleho Tlali
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
- Butha-Buthe Government Hospital, Butha-Buthe, Lesotho
| | - Moniek Bresser
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
| | - Fabrizio Tediosi
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
| | - Mathebe Kopo
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Mpho Kao
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Thomas Klimkait
- University of Basel, 4051 Basel, Switzerland
- Molecular Virology, Department of Biomedicine, University of Basel, 4051 Basel, Switzerland
| | - Manuel Battegay
- University of Basel, 4051 Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland
| | - Tracy Renée Glass
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland
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Sisira Kumara A, Samaratunge R. Relationship between healthcare utilization and household out-of-pocket healthcare expenditure: Evidence from an emerging economy with a free healthcare policy. Soc Sci Med 2019; 235:112364. [PMID: 31208779 DOI: 10.1016/j.socscimed.2019.112364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 12/28/2022]
Abstract
Despite the free public healthcare policy in Sri Lanka, households' out-of-pocket healthcare expenditures are steadily increasing. Parallel to this, there is an emerging private healthcare sector based on a user-pays approach. This study, therefore, examines the relationship between healthcare utilization and out-of-pocket healthcare expenses at household level. Using a double-hurdle model with 42,288 household observations drawn from the household income and expenditure survey (2012/2013 and 2016 waves), we find that out- and in-patient care in public hospitals under 'free healthcare policy' is positively associated with household out-of-pocket healthcare expenses, imposing a significant financial burden on the family budget. This relationship is even greater for utilization of private out- and in-patient care. The recent regulatory and fiscal interventions of the government have favourably moderated this relationship for out-patient care but not for in-patient care. The results recommend introducing public policies to further strengthen the monitoring process for private healthcare sector while ensuring the sustainability of free healthcare policy. The paper provides policy implications for richly categorized out-of-pocket healthcare expenditure and healthcare utilization types.
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Affiliation(s)
- Ajantha Sisira Kumara
- Department of Public Administration, University of Sri Jayewardenepura, Gangodawila-Nugegoda, Sri Lanka.
| | - Ramanie Samaratunge
- Department of Management, Monash Business School, Monash University, Menzies Building, Level 11, Clayton Campus, Victoria, 3800, Australia.
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Tran VT, Messou E, Mama Djima M, Ravaud P, Ekouevi DK. Patients' perspectives on how to decrease the burden of treatment: a qualitative study of HIV care in sub-Saharan Africa. BMJ Qual Saf 2019; 28:266-275. [PMID: 29706594 PMCID: PMC6860734 DOI: 10.1136/bmjqs-2017-007564] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 04/09/2018] [Accepted: 04/15/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Patients living with HIV infection (PLWH) in sub-Saharan Africa face an important burden of treatment related to everything they do to take care of their health: doctor visits, tests, regular refills, travels, and so on. In this study, we involved PLWH in proposing ideas on how to decrease their burden of treatment and assessed to what extent these propositions could be implemented in care. METHODS Adult PLWH recruited in three HIV care centres in Côte d'Ivoire participated in qualitative interviews starting with 'What do you believe are the most important things to change in your care to improve your burden of treatment?' Two independent investigators conducted a thematic analysis to identify and classify patients' propositions to decrease their burden of treatment. A group of experts involving patients, health professionals, hospital leaders and policymakers evaluated each patient proposition to assess its feasibility. RESULTS Between February and April 2017, 326 participants shared 748 ideas to decrease their burden of treatment. These ideas were grouped into 59 unique patient propositions to improve their personal care and the organisation of their hospital or clinic and/or the health system. Experts considered that 27 (46%), 19 (32%) and 13 (22%) of patients' propositions were easy, moderate and difficult, respectively, to implement. A total of 118 (36%) participants offered at least one proposition considered easily implementable by our experts. CONCLUSION Asking PLWH in sub-Saharan Africa about how their care could be improved led to identifying meaningful propositions. According to experts, half of the ideas identified could be implemented easily at low cost for minimally disruptive HIV care.
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Affiliation(s)
- Viet-Thi Tran
- METHODS Team, Centre de Recherche Epidemiologie et Statistiques Sorbonne Paris Cité (CRESS UMR 1153), Paris, France
- Centre d’Epidémiologie Clinique–Hôpital Hôtel-Dieu, Assistance Publique–Hopitaux de Paris, Paris, France
| | - Eugene Messou
- Programme PAC-CI, Centre Hospitalier Universitaire de Treichville, Abidjan, Côte d’Ivoire
| | - Mariam Mama Djima
- Programme PAC-CI, Centre Hospitalier Universitaire de Treichville, Abidjan, Côte d’Ivoire
- Institut Pasteur de Cote d’Ivoire, Abidjan, Côte d’Ivoire
| | - Philippe Ravaud
- Centre d’Epidémiologie Clinique–Hôpital Hôtel-Dieu, Assistance Publique–Hopitaux de Paris, Paris, France
| | - Didier K Ekouevi
- Programme PAC-CI, Centre Hospitalier Universitaire de Treichville, Abidjan, Côte d’Ivoire
- Bordeaux Population Health (UMR1219), INSERM, Bordeaux, France
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Meyer-Rath G, van Rensburg C, Chiu C, Leuner R, Jamieson L, Cohen S. The per-patient costs of HIV services in South Africa: Systematic review and application in the South African HIV Investment Case. PLoS One 2019; 14:e0210497. [PMID: 30807573 PMCID: PMC6391029 DOI: 10.1371/journal.pone.0210497] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/23/2018] [Indexed: 12/29/2022] Open
Abstract
Background In economic analyses of HIV interventions, South Africa is often used as a case in point, due to the availability of good epidemiological and programme data and the global relevance of its epidemic. Few analyses however use locally relevant cost data. We reviewed available cost data as part of the South African HIV Investment Case, a modelling exercise to inform the optimal use of financial resources for the country’s HIV programme. Methods We systematically reviewed publication databases for published cost data covering a large range of HIV interventions and summarised relevant unit costs (cost per person receiving a service) for each. Where no data was found in the literature, we constructed unit costs either based on available information regarding ingredients and relevant public-sector prices, or based on expenditure records. Results Only 42 (5%) of 1,047 records included in our full-text review reported primary cost data on HIV interventions in South Africa, with 71% of included papers covering ART. Other papers detailed the costs of HCT, MMC, palliative and inpatient care; no papers were found on the costs of PrEP, social and behaviour change communication, and PMTCT. The results informed unit costs for 5 of 11 intervention categories included in the Investment Case, with the remainder costed based on ingredients (35%) and expenditure data (10%). Conclusions A large number of modelled economic analyses of HIV interventions in South Africa use as inputs the same, often outdated, cost analyses, without reference to additional literature review. More primary cost analyses of non-ART interventions are needed.
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Affiliation(s)
- Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
- * E-mail:
| | - Craig van Rensburg
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Calvin Chiu
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rahma Leuner
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Steve Cohen
- Strategic Development Consultants, Pietermaritzburg, South Africa
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Pillai N, Foster N, Hanifa Y, Ndlovu N, Fielding K, Churchyard G, Chihota V, Grant AD, Vassall A. Patient costs incurred by people living with HIV/AIDS prior to ART initiation in primary healthcare facilities in Gauteng, South Africa. PLoS One 2019; 14:e0210622. [PMID: 30742623 PMCID: PMC6370193 DOI: 10.1371/journal.pone.0210622] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 12/29/2018] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To quantify costs to patients of accessing HIV care prior to ART initiation. MATERIALS AND METHODS Using a cross-sectional study design, costs incurred by HIV-positive patients prior to ART initiation were estimated at urban primary healthcare facilities in South Africa. Costs included direct costs, indirect (productivity) costs, carer and coping costs (value of assets sold and money borrowed). The percentage of individual income spent on healthcare was calculated and compared by patient income tertiles and CD4 count strata. RESULTS 289 patients (69% female, mean age 37 (SD: 10) years, median CD4 317 (IQR: 138-494) cells/mm3) were interviewed. The total mean monthly cost of pre-ART care was US$15.71. Indirect costs accounted for $2.59 (16.49%) of this when time was valued using the patient's reported income. The mean monthly patient costs were $31.61, $12.78, $12.65 and $11.93 for those with a CD4 count <100, 101-350, 351-500 and >500 cells/mm3 respectively. The percentage of individual income spent on healthcare was 7.25% for those with a CD4 count <100 cells/mm3 and 4.05% for those with a CD4 count >500 cells/mm3. CONCLUSIONS Despite the provision of charge-free services at public clinics, care prior to ART initiation can be costly, particularly for the poor and unemployed. Our study adds to the growing body of evidence that highlights the need to consider policies to reduce the economic barriers to HIV service access, particularly for low income or unwell patient groups, such as improving access to disability grants.
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Affiliation(s)
- Natasha Pillai
- Social and Mathematical Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Yasmeen Hanifa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin Churchyard
- Aurum Institute, Johannesburg, South Africa
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet Chihota
- Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison D. Grant
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
| | - Anna Vassall
- Social and Mathematical Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Women's (health) work: A population-based, cross-sectional study of gender differences in time spent seeking health care in Malawi. PLoS One 2018; 13:e0209586. [PMID: 30576388 PMCID: PMC6303093 DOI: 10.1371/journal.pone.0209586] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/08/2018] [Indexed: 11/19/2022] Open
Abstract
Background There has been a notable expansion in routine health care in sub-Saharan Africa. While heath care is nominally free in many contexts, the time required to access services reflects an opportunity cost that may be substantial and highly gendered, reflecting the gendered nature of health care guidelines and patterns of use. The time costs of health care use, however, have rarely been systematically assessed at the population-level. Methods Data come from the 2015 wave of a population-based cohort study of young adults in southern Malawi during which 1,453 women and 407 men between the ages of 21 and 31 were interviewed. We calculated the time spent seeking health care over a two-month period, disaggregating findings by men, recently-pregnant women, mothers with children under two years old, and “other women”. We then extrapolated the time required for specific services to estimate the time that would be needed for each subpopulation to meet government recommendations for routine health services over the course of a year. Results Approximately 60% of women and 22% of men attended at least one health care visit during the preceding two months. Women spent six times as long seeking care as did men (t = -4.414, p<0.001), with an average 6.4 hours seeking care over a two-month period compared to 1 hour for men. In order to meet government recommendations for routine health services, HIV-negative women would need to spend between 19 and 63 hours annually seeking health care compared to only three hours for men. An additional 40 hours would be required of HIV-positive individuals initiating antiretroviral care. Conclusions Women in Malawi spend a considerable amount of time seeking routine health care services, while men spend almost none. The substantial time women spend seeking health care exacerbates their time poverty and constrains opportunities for other meaningful activities. At the same time, few health care guidelines pertain to men who thus have little interaction with the health care system. Additional public health strategies such as integration of services for those services frequently used by women and specific guidelines and outreach for men are urgently needed.
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Bacha JM, Aririguzo LC, Mng'ong'o V, Malingoti B, Wanless RS, Ngo K, Campbell LR, Schutze GE. The Standardized Pediatric Expedited Encounters for ART Drugs Initiative (SPEEDI): description and evaluation of an innovative pediatric, adolescent, and young adult antiretroviral service delivery model in Tanzania. BMC Infect Dis 2018; 18:448. [PMID: 30176821 PMCID: PMC6122709 DOI: 10.1186/s12879-018-3331-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As countries scale up antiretroviral therapy (ART) for children, innovative strategies to deliver quality services to children are needed. Differentiated ART delivery models have been successful in adults, but no such program has been described in children. We describe the Standardized Pediatric Expedited Encounters for ART Drugs Initiative (SPEEDI). METHODS Descriptive analysis of patients eligible for SPEEDI was done via retrospective review of children, adolescents, and young adults on ART at the Baylor Centre of Excellence (COE) in Mbeya, Tanzania between January 2013 and December 2015. Eligibility for SPEEDI visits included the following: stable children, adolescents, and young adults on ART for approximately 3 months or longer, no medical or social complications, good adherence to ART, and presence of reliable caregiver. During a SPEEDI visit, patients were fast tracked in triage to collect medications directly without physically seeing a clinician. SPEEDI patients came to clinic every two months, and alternated SPEEDI visits with standard visits. Baseline characteristics, mortality, and lost-to-follow up rates of SPEEDI patients were analyzed. RESULTS One thousand one hundred sixty-four patients utilized SPEEDI, totaling 3493 SPEEDI visits. SPEEDI reached 51.3% (1164/2269) of pediatric ART patients, accounting for 7.7% (3493/44489) of total patient encounters. SPEEDI patients were 52% (605/1164) female, median age of 11.7 years (range 1.2-25.5 yr), median time on ART of 21 months (range 4-130 months) and 83.5% (964/1155) categorized as no or mild HIV-associated immunodeficiency. SPEEDI patients had good outcomes (98.8%), low LTFU (0.1%) and low mortality rates (0.61 deaths per 100 patient-years). CONCLUSION SPEEDI was an effective model for delivering ART to children, adolescents, and young adults in our setting, leading to good clinical outcomes, low mortality, and low LTFU. The SPEEDI program safely and effectively expedited and spaced out ART visits for children, adolescents, and young adults, and can serve as an adaptable ART delivery model for other resource limited settings.
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Affiliation(s)
- Jason M Bacha
- Pediatrics, Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Box 2663, Mbeya, PO, Tanzania. .,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Lynda C Aririguzo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Veronica Mng'ong'o
- Pediatrics, Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Box 2663, Mbeya, PO, Tanzania
| | - Beatrice Malingoti
- Pediatrics, Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Box 2663, Mbeya, PO, Tanzania
| | - Richard S Wanless
- Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Katherine Ngo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Liane R Campbell
- Pediatrics, Baylor College of Medicine Children's Foundation - Tanzania, Centre of Excellence at Mbeya Zonal Referral Hospital, Box 2663, Mbeya, PO, Tanzania.,Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Gordon E Schutze
- Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Geldsetzer P, Francis JM, Sando D, Asmus G, Lema IA, Mboggo E, Koda H, Lwezaula S, Ambikapathi R, Fawzi W, Ulenga N, Bärnighausen T. Community delivery of antiretroviral drugs: A non-inferiority cluster-randomized pragmatic trial in Dar es Salaam, Tanzania. PLoS Med 2018; 15:e1002659. [PMID: 30231024 PMCID: PMC6145501 DOI: 10.1371/journal.pmed.1002659] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/23/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With the increase in people living with HIV in sub-Saharan Africa and expanding eligibility criteria for antiretroviral therapy (ART), there is intense interest in the use of novel delivery models that allow understaffed health systems to successfully deal with an increasing demand for antiretroviral drugs (ARVs). This pragmatic randomized controlled trial in Dar es Salaam, Tanzania, evaluated a novel model of ARV community delivery: lay health workers (home-based carers [HBCs]) deliver ARVs to the homes of patients who are clinically stable on ART, while nurses and physicians deliver standard facility-based care for patients who are clinically unstable. Specifically, the trial aimed to assess whether the ARV community delivery model performed at least equally well in averting virological failure as the standard of care (facility-based care for all ART patients). METHODS AND FINDINGS The study took place from March 1, 2016, to October 27, 2017. All (48) healthcare facilities in Dar es Salaam that provided ART and had an affiliated team of public-sector HBCs were randomized 1:1 to either (i) ARV community delivery (intervention) or (ii) the standard of care (control). Our prespecified primary endpoint was the proportion of adult non-pregnant ART patients with virological failure at the end of the study period. The prespecified margin of non-inferiority was a risk ratio (RR) of 1.45. The mean follow-up period was 326 days. We obtained intent-to-treat (ITT) RRs using a log-binomial model adjusting standard errors for clustering at the level of the healthcare facility. A total of 2,172 patients were enrolled at intervention (1,163 patients) and control (1,009 patients) facilities. Of the 1,163 patients in the intervention arm, 516 (44.4%) were both clinically stable on ART and opted to receive ARVs in their homes or at another meeting point of their choosing in the community. At the end of the study period, 10.9% (95/872) of patients in the control arm and 9.7% (91/943) in the intervention arm were failing virologically. The ITT RR for virological failure demonstrated non-inferiority of the ARV community delivery model (RR 0.89 [1-sided 95% CI 0.00-1.18]). We observed no significant difference between study arms in self-reported patient healthcare expenditures over the last 6 months before study exit. Of those who received ARVs in the community, 97.2% (95% CI 94.7%-98.7%) reported being either "satisfied" or "very satisfied" with the program. Other than loss to follow-up (18.9% in the intervention and 13.6% in the control arm), the main limitation of this trial was that substantial decongestion of healthcare facilities was not achieved, thus making the logic for our preregistered ITT approach (which includes those ineligible to receive ARVs at home in the intervention sample) less compelling. CONCLUSIONS In this study, an ARV community delivery model performed at least as well as the standard of care regarding the critical health indicator of virological failure. The intervention did not significantly reduce patient healthcare expenditures, but satisfaction with the program was high and it is likely to save patients time. Policy-makers should consider piloting, evaluating, and scaling more ambitious ARV community delivery programs that can reach higher proportions of ART patients. TRIAL REGISTRATION ClinicalTrials.gov NCT02711293.
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Affiliation(s)
- Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Joel M. Francis
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Management and Development for Health, Dar es Salaam, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Gerda Asmus
- Faculty of Economics and Social Sciences, Heidelberg University, Heidelberg, Germany
| | - Irene A. Lema
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Eric Mboggo
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Happiness Koda
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Sharon Lwezaula
- Tanzanian National AIDS Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Ramya Ambikapathi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Africa Health Research Institute, KwaZulu-Natal, South Africa
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Why do people living with HIV not initiate treatment? A systematic review of qualitative evidence from low- and middle-income countries. Soc Sci Med 2018; 213:72-84. [PMID: 30059900 PMCID: PMC6813776 DOI: 10.1016/j.socscimed.2018.05.048] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 05/15/2018] [Accepted: 05/25/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Many people living with HIV (PLWH) who are eligible for antiretroviral therapy (ART) do not initiate treatment, leading to excess morbidity, mortality, and viral transmission. As countries move to treat all PLWH at diagnosis, it is critical to understand reasons for non-initiation. METHODS We conducted a systematic review of the qualitative literature on reasons for ART non-initiation in low- and middle-income countries. We screened 1376 titles, 680 abstracts, and 154 full-text reports of English-language qualitative studies published January 2000-April 2017; 20 met criteria for inclusion. Our analysis involved three steps. First, we used a "thematic synthesis" approach, identifying supply-side (facility) and demand-side (patient) factors commonly cited across different studies and organizing these factors into themes. Second, we conducted a theoretical mapping exercise, developing an explanatory model for patients' decision-making process to start (or not to start) ART, based on inductive analysis of evidence reviewed. Third, we used this explanatory model to identify opportunities to intervene to increase ART uptake. RESULTS Demand-side factors implicated in decisions not to start ART included feeling healthy, low social support, gender norms, HIV stigma, and difficulties translating intentions into actions. Supply-side factors included high care-seeking costs, concerns about confidentiality, low-quality health services, recommended lifestyle changes, and incomplete knowledge of treatment benefits. Developing an explanatory model, which we labeled the Transdisciplinary Model of Health Decision-Making, we posited that contextual factors determine the costs and benefits of ART; patients perceive this context (through cognitive and emotional appraisals) and form an intention whether or not to start; and these intentions may (or may not) be translated into actions. Interventions can target each of these three stages. CONCLUSIONS Reasons for not starting ART included consistent themes across studies. Future interventions could: (1) provide information on the large health and prevention benefits of ART and the low side effects of current regimens; (2) reduce stigma at the patient and community levels and increase confidentiality where stigma persists; (3) remove lifestyle requirements and support patients in integrating ART into their lives; and (4) alleviate economic burdens of ART. Interventions addressing reasons for non-initiation will be critical to the success of HIV "treat all" strategies.
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Tran VT, Mama Djima M, Messou E, Moisan J, Grégoire JP, Ekouevi DK. Avoidable workload of care for patients living with HIV infection in Abidjan, Côte d'Ivoire: A cross-sectional study. PLoS One 2018; 13:e0202911. [PMID: 30142165 PMCID: PMC6108500 DOI: 10.1371/journal.pone.0202911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 08/10/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE People living with HIV infection (PLWHIV) in Sub-Saharan Africa cope with an increasing workload of care (doctor visits, lab tests, medication management, refills, etc.) in a context of poor health service organization. We aimed to describe the workload of care for PLWHIV in Sub-Saharan Africa and assess to what extent simple adjustments in care organization could reduce this workload of care. METHODS Adult PLWHIV under antiretroviral treatment for at least 1 year were recruited in three centers (two public, one private) in Abidjan, Côte d'Ivoire. Using methods inspired from sociology, we precisely described all health-related activities (HRAs) performed by patients, in 1 month, in terms of time, money and opportunity costs. Then, we assessed the theoretical avoidable workload of care if patients' visits and tests had been grouped on the same days. RESULTS We enrolled 476 PLWHIV in the study. Patients devoted 6.7 hours (SD = 6.3), on average, in HRAs per month and spent 5% (SD = 11) of their monthly revenue, on average, on health activities. However, we found great inter-patient heterogeneity in the mixture of activities performed (managing medications; dietary recommendations; visits, tests, support groups; administrative tasks; etc.) and their time allocation, temporal dispersion and opportunity costs (personal, familial, social or professional costs). For 22% of patients, grouping activities on the same days could reduce both time and cost requirements by 20%. CONCLUSION PLWHIV in Côte d'Ivoire have a heavy workload of care. Grouping visits and tests on the same days may be a simple and feasible way to reduce patients' investment of time and money in their care.
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Affiliation(s)
- Viet-Thi Tran
- Programme PAC-CI, Abidjan, Côte d’Ivoire
- METHODS Team, Centre de recherche en Epidémiologie et Statistiques Sorbonne Paris Cité (CRESS, UMR1153), Paris, France
- * E-mail:
| | - Mariam Mama Djima
- Programme PAC-CI, Abidjan, Côte d’Ivoire
- Institut Pasteur, Abidjan, Côte d’Ivoire
- Faculty of Pharmacy of Laval University, Québec, Canada
| | | | | | | | - Didier K. Ekouevi
- Programme PAC-CI, Abidjan, Côte d’Ivoire
- Bordeaux Population Health (UMR1219), Bordeaux, France
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